Crash Protection for Child Passengers - UMTRI

Crash Protection for Child Passengers - UMTRI
UMTRI Research Review
July-September 2000, Vol. 31, No. 3
Crash Protection
for Child Passengers
A Review of Best Practice
by Kathleen Weber
hild restraint systems provide specialized protection for small occupants
whose body structures are still immature and growing. There is a wide variety of
systems from which to choose, and different
types of restraints are appropriate for children
of different ages and sizes. Even with the most
appropriate child restraint (CR), however, the
way in which it is installed and used can have
an effect on its performance. This review describes the theory behind the design of occupant restraint systems and applies these principles to the special needs of children. A distinction is made between child restraints, which
themselves provide the restraint structure, and
positioning devices, such as boosters, which
help the vehicle belt fit the child. Throughout
each section, current concepts of best practice
are given, including the changes brought on
by passenger airbags, and future directions are
In a vehicle crash, there are actually a series of
collisions. The primary impact is between the vehicle and another object, while the occupants continue to travel forward at the precrash speed. Unrestrained occupants then come to an abrupt stop
against the decelerating vehicle interior or the
ground outside the vehicle. Restrained occupants
collide with their belts, or other restraint system,
very soon after the primary collision. Finally, there
are collisions between the body’s internal organs
and the bony structures enclosing them, which can
be mitigated by the use of occupant restraint systems.
The front ends of vehicles are designed to crush
during impact, thereby absorbing crash energy and
allowing the passenger compartment to come to a
stop over a greater distance (and longer time) than
does the front bumper. By tightly coupling the
occupants to the passenger compartment structure,
through the use of snug fitting belts, the occupants
ride down the crash with the vehicle. For adults,
there is usually only one link, such as a lap/shoulder belt, between the occupant and the vehicle.
For children, however, there are usually two links:
the belt or other system holding the child restraint
to the vehicle, and the harness or other structure
holding the child.
In the case of belts, which absorb little energy
themselves, the tighter they are adjusted prior to
the crash, the lower will be the body’s initial deceleration into the belts. Other supplemental protection systems, such as padding or airbags, can
absorb impact energy between the occupant and
the vehicle interior or, in the case of side-impact
airbags, provide a layer of protection between the
body and an intruding vehicle or other structure.
Controlling the rate of the body’s overall deceleration reduces not only the forces acting on the
body’s surface but also the differential motion
between the skeleton and the internal organs, such
as the skull and brain. Hard surfaces or loose
seatbelts, on the other hand, stop the body abruptly
when they are finally struck and pulled tight, applying more force to the body surface and giving
its contents a harder jolt.
Tight coupling to the crushing vehicle addresses only part of the problem, however. To
optimize the body’s impact tolerance, the remaining loads must be distributed as widely as possible over the body’s strongest parts. For adults,
who prefer to face the front of the vehicle (or must
do so to drive), this includes the shoulders, the
pelvis, and secondarily the chest. For children, especially infants, restraint over larger and sometimes different body areas is necessary. Multiple
straps, deformable shields, and facing rearward
help take care of these needs.
Proper placement and good fit are important
for effective occupant restraint. Serious restraintinduced injuries can occur when the belts are misplaced over body areas having no protective bony
structure. Such misplacement of a lap belt can
occur during a crash if the belt is loose or, with
small children, is not held in place by a crotch
strap or other positioning device, such as booster
belt guides. A lap belt that is placed or rides up
above the hips can intrude into the soft abdomen
and rupture or lacerate internal organs.100,101 Moreover, in the absence of a shoulder restraint, a lap
belt worn high can act as a fulcrum around which
the lumbar spine flexes, possibly causing separation or fracture of the lumbar vertebrae in a severe crash.49,59
Despite the potential for belt-induced injuries,
belt-based restraint systems have significant advantages over airbag
systems. They offer
protection in a variety
of crash directions, including rollovers, and
throughout the course
of multiple impacts.
Moreover, the force on
the occupant is proportional to the mass of
that occupant. For example, a man weighing
80 kg will experience a
much greater load into
the belts on his chest and pelvis than a child weighing only 20 kg. Even though the child’s bony structure and connective tissue may be weaker than
the adult’s, the child’s weight is so much less that
the injury potential from contact with belts or other
static surfaces is less. Current generation airbags,
on the other hand, generate the same amount of
deployment force and resistance to deflation regardless of occupant size or proximity to the bag.
This puts children and other small occupants at
much greater risk of injury than large, high-mass
occupants and is among the reasons children
should not ride in seats with frontal-impact
airbags. The suitability of side-impact airbags for
children is a topic of current investigation.
The primary goal of any occupant protection
system is to keep the central nervous system from
being injured. Broken bones will mend and soft
tissue will heal, but damage to the brain and spinal cord is currently irreversible. In the design of
restraint systems, it may therefore be necessary
to put the extremities, ribs, or even abdominal viscera at some risk in order to ensure that the brain
and spinal cord will be protected.
Child restraint designs vary with the size of
the child, the direction the child faces, the type of
internal restraining system, and the method of installation. All CRs, however, work on the principle of coupling the child as tightly as possible
to the vehicle. Historically in North America, the
CR has been attached to the vehicle with the existing seatbelts, sometimes supplemented by an
additional top tether strap. The child is then secured to the CR with a separate harness and/or
other restraining surface (shield). This results in
two links between the vehicle and the occupant,
rather than only one. It is therefore critical that
both the seatbelt and the harness, for instance, be
as tight as possible to allow the child to ride down
the crash with the vehicle.
When this system has been properly used and
secured, child restraints have been estimated to
reduce the risk of death and serious injury by approximately 70%.50 By comparison, estimates of
fatality reduction to adults in lap/shoulder belts
for the same time period averaged about 50%.25,43,94
For further comparison, “partially misused” CRs
were estimated to be only 44% effective, and lap
belts alone with children age 1 through 4 only
33%.50 More recent analyses of fatality reduction
alone for child restraints, without regard to misuse, still estimated about a 70% reduction for children under age 1 in passenger cars but only a 54%
(although steadily increasing) reduction for children age 1 through 4.40,95 Seatbelt use by the latter
group resulted in a 47% reduction in fatalities.
Finally, a recent analysis of children 2 through 5
in crashes indicates that those in seatbelts are 3.5
times more likely to suffer moderate to severe injuries, particularly to the head, than those in child
restraint systems.129
The following sections first address the installation issues common to all child restraints and
then discuss the different types of restraint configurations and types appropriate for children of
different size and maturity.
Installation Challenges and Changes
The original function of seatbelts was to restrain only adult-size occupants, and some beltassembly design parameters are in conflict with
those that would best secure CRs. These parameters include belt anchor location, buckle size, and
type of retractor and latchplate. These and other
issues regarding child restraint compatibility with
vehicle belts and seats are addressed in an SAE
Recommended Practice (SAE J1819, 1994).105
Unfortunately, however, not all products comply
with this voluntary standard, nor have all problems been solved. Tight installation with a seatbelt
continues to be difficult to achieve in many cases.
Built-In Child Restraints
Another approach, pursued in Sweden and
eventually in North America as well, is called a
built-in or integrated child restraint.54,112 Built-ins
(figure 1) have the advantage of linking the child
directly to the vehicle and eliminating installation
errors. The disadvantage, of course, is that integrated restraints cannot be moved to another vehicle nor removed when no longer needed. This
drawback, in combination with reluctant or inadequate marketing by dealerships, has resulted in
low sales and an expected reduction in availability in the future, although the National Transportation Safety Board has recommended that all
automobile manufacturers offer integrated child
restraints in their passenger vehicles.90
Top Tethers
Some forward-facing restraint designs of
the 1970s and early
1980s depended on a
top attachment strap
and vehicle anchor, in
addition to the seatbelt,
to meet the federal performance standard (49
CFR 571.213) and keep
a child’s head from
traveling beyond a safe
limit during a severe
frontal crash. It was
found, however, that
few people actually installed the anchors in
their vehicles. 103 In
Figure 1. Built-in child restraint.
1986 the rule was
changed to require mass market restraints to meet
the 30-mph crash test requirements without a top
tether (51 FR 5335). During this time Canada continued to support the use of tethers by maintaining a more stringent head excursion limit that
could only be met reliably by using a tether. In
1989 Canada began requiring vehicle manufacturers to provide readily usable locations for tether
anchor installation (SOR/86-975), and these features were included in most U.S. passenger vehicles as well.
As difficulties with belt and seat compatibilities increased and tether anchors became easier
to install, interest in tethers again surfaced. In the
last few years, U.S. CRs have been increasingly
available with standard or add-on tethers for forward-facing use, and new head-excursion requirements in the U.S. (64 FR 10815), which are consistent with Canada’s, now require tethers on virtually all forward-facing CRs as of September
1999. New Canadian and U.S. regulations also
required factory-installed, user-ready anchors in
passenger cars beginning in September 1999 and
light trucks and vans in September 2000 (SOR/
98-457, CMVSS 210.1; 64 FR 10823, 49 CFR
571.225). There is an effort underway by child
restraint advocates to encourage and facilitate the
installation of tether anchors in older vehicles as
It is anticipated that tethers, which consumers
profess to appreciate and want,28,97 will signifiUMTRI RESEARCH REVIEW
cantly improve the perception of installation security, as well as the crash performance of child
restraints on which they are used. A few CR manufacturers are also recommending the use of a tether
for rear-facing restraints, to be discussed later.
New Anchorages and Attachments
A concept called ISOFIX was first proposed
in 1991115 and finally completed as an international
standard in 1999.44 The original proposal was for
standard rigid interface hardware to be available
in all vehicles and on all child restraints, so that
CR installation would entirely bypass vehicle belts
and the CR would not rely on the vehicle seat cushion for support. In addition to a likely reduction
in misinstallation and an improvement in crash
performance, the creators of the concept hoped
there could be an electrical interface to do such
things as disable a passenger airbag.
As the concept was tested and developed, it
became apparent that two lower anchors at the
seat bight (the intersection of the seat back and
cushion) would be insufficient to isolate the CR
from the seat cushion, and alternative additional
anchors or reactive devices were proposed and
evaluated.70 No single system proved to appeal to
all markets, however, so the final definition included two rigid lower anchorages “and a means
to limit the pitch rotation of the CRS.” The system favored in North America includes a top tether
and will be phased into the U.S. market by September 1, 2002 (64 FR 10786, 49 CFR 571.213
and 571.225). The system has also been given the
Bars Installed
in Vehicle Seat
more user-friendly name of LATCH, which stands
for Lower Anchors and Tethers for CHildren.
Canada has a similar proposal, announced in
March 1999 (C.Gaz. I, 133:629) but not yet finalized. In both jurisdictions, all CRs will continue
to be installable using seatbelts in older vehicles
and in seating positions not equipped with the
lower anchors. The U.S. regulation, for instance,
requires only two positions to have the lower anchors, and unfortunately they are likely to be
omitted from the center rear-seat position. That
position, if it exists, is required to have a userready tether anchor, however.
The ISOFIX standard gives preference to adjustable rigid attachments on the child restraints
but also provides for optional nonrigid attachments
consistent with the U.S. regulation. Although a
rigid interface has the potential advantage of needing only a single operation for installation or removal, and is expected to provide improved performance in many side impacts,56,69 U.S. manufacturers and regulators alike prefer to allow the
attachment technology to evolve and be tested in
the marketplace. Initial applications in North
America have therefore appeared as pairs of webbing-based attachments with individual adjustments. Top tethers, which also consist of webbing
with a standard hook, will be available for use
with either the LATCH attachments or the traditional seatbelt installation. There is, however, a
two-level certification test that guarantees the current level of crash performance even without the
tether. The LATCH configurations are illustrated
in figure 2.
Bars Installed
in Vehicle Seat
Figure 2. LATCH anchorages and attachments: (A) flexible lower
attachments plus tether, (B) rigid lower attachments plus tether.
Restraint Fitting
Australia has often
been ahead of other
countries in road safety
initiatives. In 1985, the
Traffic Authority of
New South Wales, having determined that restrained children were
being injured as a result
of incorrect installation
and adjustment (fitting)
of CRs in vehicles, established a network of
stations to assist the
public with this sometimes difficult task.33 Begun
at a local level, restraint fitting stations (RFSs)
quickly expanded throughout the populous southeastern states. RFSs are licensed by the appropriate traffic authority, and fitters must attend formal training sessions. To assist personnel at the
sites, detailed manuals have been prepared on
regulations, use laws, and design, installation, and
adjustment of all restraints and auxiliary devices
approved for use in Australia. Beyond information and advice, RFSs provide actual installation
hardware and services for tethers, shoulder belts,
and other special devices that may be required.
The stations keep regular hours, and the consumer
is charged a nominal fee that varies with the complexity of the installation.
Despite these efforts, a recent pilot observation and interview survey found 29% of infant and
child restraint installations to be “poor,” including 18% of those installed by RFSs, and only 24%
of participants had taken advantage of the service.93 As restraint installation becomes more uniform and less complex, the author suggests that
emphasis should shift away from attachment hardware to proper restraint of the child within the
The RFS concept came to the attention of the
National Transportation Safety Board, which recommended in 1999 that permanent facilities be
established in the U.S. where people could go to
obtain information about compatibility and appropriate CRs and have their child restraints checked
for correct installation and use.35 The service described is similar to what has been offered by volunteers at car seat clinics or similar check-up
events. In response, a major vehicle manufacturer
launched such a program at its dealerships. Initially only for owners of its vehicles, the program
has expanded during 2000 to include anyone needing help with installing or using child restraints.20
Seating Position and Airbags
From the early days of child restraint regulation, it has been recognized that the center rear
seat position is the safest place in the car, since it
is farthest from the outside of the vehicle, and
current injury data analyses continue to bear this
out.11 Because of parental preference and the
proven effectiveness of rear-facing CRs, however,
infants were often restrained in the front seat, especially when alone with the driver.24 The front-
seat, rear-facing child is the foundation on which
Sweden’s child protection record is based.52 In
addition, with the appearance of booster cushions
in the early 1980s and the lack of shoulder belts
in rear seats, older children were thought to benefit from sitting in front with 3-point restraints.
All this changed with the coming of passenger
airbags around 1990 and the potential for a direct
lethal blow of the airbag to a proximate child. This
device, intended for the protection of adults, has
been estimated to dramatically increase the chance
of a child fatality. Depending on the method of
analysis, increased risk factors ranging from 34%10
to more than twice that31,51 have been estimated
for children in frontal crashes. The Graham et al.
double-pair comparison, including all crash directions and all restraint conditions, has yielded a net
63% increased fatality risk among children under
13 in dual vs. driver-only airbag-equipped vehicles.31 These fatalities almost always involved
head/neck injury from direct blows by the inflating bag and/or the airbag housing cover to children who were unrestrained and/or close to the
airbag at the instant of deployment.85 A report including 27 children under 13 suffering airbag-related injuries with a range of severity indicates
that even properly restrained children are not immune,34 with eye and facial injuries elsewhere reported to be a special problem.71 Airbag injuries
to belted children, who otherwise would likely
have been unharmed, are also reported in Canada
and include one fatality.75
Side-impact airbags are also beginning to appear in increasing numbers, but less than 1% of
these are as yet in rear seats.32 There are no studies published thus far that indicate a child properly restrained in a CR is at risk from current sideimpact airbags, but laboratory simulations indicate that unrestrained and out-of-position children
could be injured.23 Industry efforts are therefore
focusing on developing side airbags and test procedures that will minimize injury risk to such occupants, both adults and children, recognizing that
this risk can never be zero.73 As of May 2000, the
National Highway Traffic Safety Administration
(NHTSA) had recorded 47 crashes involving sideairbag deployments, among which only a single
child, age 3 and unrestrained in the front seat, suffered a minor injury from the door-mounted airbag
cover flap.87
Airbags, however, are not the only factor to
New federal regulations are aimed at ensuring
that future airbags will either not deploy when the
occupant is too close or would not cause harm if
deployment occurs (65 FR 30680, 49 CFR
571.208), but the new systems will not have to be
implemented until September 1, 2003. The general message to parents today is to restrain all preteens in the back seat, with cautions about behavior and distance from any airbag housing when
exceptions must be made. A rear-facing child restraint, however, must never be installed in a seat
position with an active frontal-impact airbag.
Figure 3. Rear-facing child restraints: (A) rear-facing only,
(B) rear-facing convertible.
consider when seating a child in a vehicle. Many
statistical studies show that the rear seat is a more
benign environment than the front for all occupants, almost without regard to restraint status.
Braver et al. found an overall rear-seat vs. frontseat fatality reduction for children under 13 of 35%
in vehicles with no airbags and 46% in vehicles
with passenger airbags. The only two configurations for which the front seat was better were (1)
rear impacts for all ages and (2) when older children with lap/shoulder belts in front were compared to those with no restraint in back.12 Most
recently, Berg et al. studied a large data set of children, among which 40% were unrestrained, and
confirmed that either or both rear seat use and appropriate restraint significantly reduce serious injuries and fatalities in serious crashes.9
Figure 4. 6-month size dummy during 48 km/h crash test showing
(A) head/neck protection in rear-facing child restraint, compared to
(B) head exposure and neck tension in forward-facing child restraint.
Rear-Facing Child Restraints
There are two types of restraint systems that
face the child toward the rear of the vehicle. One
(figure 3A) is designed to be used rear-facing only
(RFO), often includes a carrying handle, and may
have a detachable base for easier repeated installation. These can accommodate a child up to only
9 or 10 kg (20 or 22 lb), depending on the height
of the head/back support. The second type (figure
3B) is a rear-facing “convertible” (RFC) restraint,
so named because the same device can be installed
in either a rear- or a forward-facing orientation. It
is larger than an RFO and can accommodate a
child of greater weight in the rear-facing position.
Some RFCs are still limited to 10 kg, but many
list 13.5 kg (30 lb) as the upper weight limit. Beyond weight, the effective limit for either type is
the seated height of the child, the top of whose
head should not be above the top of the restraint,
to minimize the risk of head-contact and neckcompression injury. When a child outgrows an
RFO, it should then be restrained in an RFC until
at least the age of one year.5,121
Both types of rear-facing CRs are anchored in
place with a seatbelt or LATCH attachments, and
internal harness straps or straps plus a shield secure the infant’s body in the shell. In a frontal impact, the crash forces are transferred from the back
of the restraint to the infant’s back, which is the
infant’s strongest body surface, while the restraint
also supports the infant’s head (figure 4A). The
movement of the head and neck in unison with
the torso during a crash eliminates severe tension
and flexion forces on the neck that can occur with
forward-facing occupants (figure 4B). Further explanation and field validation of this injury risk
are discussed in the context for forward-facing restraints.
Properly used, rear-facing child restraints
(RFCRs) have proven to be extremely effective
in actual crashes,80,88,98 and experience in Sweden
has shown that children through the age of 3 can
benefit as well.47,52 These large RFCRs (figure 5)
sit away from the vehicle seatback to give the child
more leg room and have an additional strap or
other device to prevent rearward rotation. These
restraints have extremely low injury and fatality
rates, with estimates of injury-reduction effectiveness as high as 96% when compared to the unrestrained child. From 1992 through June 1997, only
9 children properly restrained rear-facing have
died in motor vehicle crashes in Sweden, and all
of these involved catastrophic crashes with severe
intrusion and few other survivors.126
Airbags and Rear-Facing Restraints
These two restraint devices definitely do not
mix. Airbags are stored in the instrument panel
and need a certain amount of space in which to
inflate before they begin to act as energy-absorbing cushions for larger occupants. A rear-facing
restraint in the front seat places the child’s head
and body very close to the airbag housing. When
current airbags deploy in a crash, whether severe
or moderate, they emerge in a small folded wad
at very high speed—as much as 300 km/h. If an
airbag hits the back of a RFCR while it is still
inflating, it will strike with considerable force. Accelerations measured at the heads of infant dummies in this situation range from 100 to 200 g,117
with only about 50 g considered tolerable for children represented by a 6-month size dummy.78 The
sequence shown in figure 6 includes this initial
impact and the continuing motion of the RFCR
toward the vehicle seatback. Many people mistakenly think that the dangerous aspect of this configuration is the “crushing” of the child's head
against the seatback.
Laboratory measurements have found,
however, that these
forces are not significant, and by then the
fatal injury has already
As of June 2000, ten
properly restrained
rear-facing infants and
another 8 in unsecured
or misbelted RFCRs
had been killed in the
U.S. by deploying passenger airbags in otherFigure 5. Large Swedish rear-facing
child restraint.
crashes.86 (Another infant was killed by a driver airbag while riding on
the driver’s lap.85) After peaking in 1996, the number of such deaths have steadily decreased, due
largely to an intensive public awareness campaign,
with the last fatal case recorded in April 1999.
Although it may be possible to mitigate this severe interaction with the depowered or multistage
airbags that have entered the vehicle fleet, and
some believe an infant restraint can be made to
deflect and/or absorb airbag forces,18 the only reliable ways to protect an infant from airbag injury
are to disconnect the bag or to restrain the child in
the rear seat.
Back Angle for Frontal Impact Protection
For reasonable protection and comfort of a
newborn or very young infant, the rear-facing restraint should be installed so that the back surface
Figure 6. Airbag deployment sequence showing initial injuryproducing impact of airbag against child restraint and continuing
motion of child restraint toward vehicle seatback.
is reclined just enough
to allow the baby’s
head to lie back comfortably, but not more
than 45° from vertical.
Beyond this angle, the
force to restrain the
child starts to be exceeded by the force to
project the baby toward
the front of the vehicle.
As the child grows, becomes heavier, and can
hold its head erect, the
angle should be decreased, making the reFigure 7. Back angle range for rear-facing
straint more upright, to
child restraint.102
provide better crash
protection (figure 7). If a rear-facing restraint is
installed in a rear seat with its back against the
seat in front, this will help limit a further increase
in back angle during a crash and provide the best
protection. In Australia, tether straps are routed
rearward from RFCRs and attached to an anchor
to achieve an even better effect (figure 8A). This
tethering not only maintains the initial angle but
also allows the child to ride down the crash with
the crushing vehicle.
Early designers of RFCRs took care in determining the optimum back angle using dynamic
testing and consultation with pediatricians.26 They
began with 40° from vertical but decided that a
more upright angle of only 15° was needed “to
obtain the desired restraint and load distribution.”
These tests, however, were apparently conducted
without the benefit of straps, which, if snug and
routed through slots at or below the child’s shoulders, will help contain the child’s body during its
tendency to ramp up the back of a reclined restraint.
Field experience, feedback to manufacturers,
and further input from pediatricians have indicated
that an angle greater than 30° from vertical is
needed for comfort of a newborn or a resting child
to keep its head from flopping over and potentially pinching off the airway. Ensuring that the
head is in contact with the CR back is also best
for crash protection. At least one major child restraint manufacturer sets its target angle at 35°
from vertical through the use of a visual indicator, while others aim for 45°. If for any medical
reason a baby needs to be reclined at an angle
greater than 45°, however, this child should be
restrained in a car bed, discussed below.
Side and Other Impact Directions
In lateral or oblique crashes, rear-facing CRs
that are installed with a lap belt will swivel somewhat in the direction of the impact, which was
originally considered to be of benefit to the infant
occupant.26 Research in support of ISOFIX anchors and improved side impact protection for
children, however, indicates that this feature may
be a disbenefit for the center or nonstruck side,
but that a flexible vs. a rigid installation is probably not significant for the struck side, where impact to the CR and child occurs before virtually
any CR movement.66,96 More important are deep
side structures and energy-absorbing
padding in the head area, so that the
head remains confined and the force
driving the intruding door is attenuated.53,56 On the nonstruck side, rigid
or very tight belt attachments that do
not slip relative to the CR help maintain the child’s position in the CR and
away from the impact.13,69 For such installations, a tether anchored rearward
does not appear to provide significant
additional protection in side impacts,
but it can improve performance with
loose or suboptimal belt-based systems.
Figure 8. Tether configurations for rear-facing child restraints:
In rear-end and rollover crashes, the
(A) Australian method (rearward), (B) Swedish method (forward, down).
shoulder straps provide containment
and attachment of the child to the RFCR, which
may rotate up against the vehicle seatback. Although originally touted as a benefit by the early
designers to protect the infant from flying debris,26
many RFOs and most RFCs now have too high a
profile next to the vehicle seatback to rotate, without apparent sacrifice to safety. A few RFCs provide a tether strap that can be attached near the
floor to the seat in front of the CR to inhibit all
such movement in a rear impact or during rebound
from a frontal impact (figure 8B). This does induce loading on the neck, but forces are expected
to be quite low and have not been known to generate injuries among Swedish children. The benefit in terms of installation stability and a fixed
restraint for the larger rear-facing child undoubtedly outweighs the low risk of neck injury.
Harnesses and Fit
RFO harnesses have traditionally been limited
to a pair of shoulder straps coming together at a
buckle. Recent models, however, include 5-point
harnesses, which provide more lateral support and
restraint for the infant. RFCs may have 5-point
harnesses or a harness/shield combination (figure
9), but the latter should not be selected for use
with infants, because they cannot be made to fit a
small body tightly and the shield may interact with
a small child’s neck or face.5
Premature and low birth-weight infants may
be so small that even RFO restraints seem too big.
If the infant’s head or body needs lateral support,
padding can be placed between the infant and the
side of the restraint. Firm padding, such as a rolled
towel, can also be placed between the infant and
the crotch strap to keep the infant from slouching.5 Thick, soft padding should not, however, be
placed under the infant, behind its back, or between the infant and the shoulder straps. Such
padding will compress during an impact, leaving
the harness loose on the infant’s body and allowing increased ramping toward the front of the vehicle.
It is common practice to use an RFO with a
newborn and continue to use it until it is outgrown
by weight or seated height. This usually happens,
however, after only a few months and before it is
advisable to face a child forward.
It is very important that the child then move to
a convertible CR and still be restrained in the rearfacing position. This is a different message than
Figure 9. Restraining configurations:
(A) 5-point harness, (B) tray shield, (C) T-shield.
the one parents may hear from friends or even
some pediatricians or CR manufacturers, who
believe that an RFO will take the child through
the entire rear-facing period. This is rarely the case.
Car-Bed Restraints
These restraints have historically been used
more often in Europe and Australia but have penetrated the North American market because of
concerns about premature infants with positional
apnea.128 The American Academy of Pediatrics
currently recommends that infants born at less than
37 weeks gestation be monitored in a semi-upright position prior to discharge to detect possible
apnea, bradycardia, or oxygen desaturation.4,7 For
infants with documented breathing problems, a
car bed is a suitable alternative to an RFO. There
are currently three models available in the U.S.,
accommodating a range of infant sizes, from very
low birth weight to an average 1-year-old.
In a car-bed restraint (figure 10), the infant lies
flat, preferably on its back or side, and the bed is
placed on the vehicle seat, with its long axis perpendicular to the direction of travel and the baby’s
head toward the center of the vehicle (not next to
the door). In a frontal crash, the forces are distributed along the entire side of the infant’s body,
while a harness or other containment device keeps
the baby in place during rebound or rollover. In a
side impact, however, the infant’s head and neck
are theoretically more vulnerable in a car bed than
in a rear-facing restraint, especially if the impact
is on the side nearest the head and there is signifiUMTRI RESEARCH REVIEW
cant intrusion.118 Experience elsewhere and
several years of availability and use in this
country, however, have
not revealed any protection deficiencies
with this configuration.
Potential advantages of using a car bed
with an infant with special medical needs are
that a baby in the rear
seat can be more easily
monitored visually by
Figure 10. Car bed restraint.30
the driver and, according to two manufacturers’ statements, the bed can also be installed in a
seat with a passenger airbag. Testing available for
public scrutiny, however, does not appear to be
adequate to prove this assertion under all possible
circumstances. Although top-mounted bags will
no doubt miss the car bed, it is less certain that no
midmount bags will impact the car bed with sufficient force to cause injury. At this time, prudence
and caution dictate that car beds be used only in
the rear seat unless the airbag is disconnected. If
front-seat use is necessary, however, the seat
should be in its farthest rearward position.
Forward-Facing Child Restraints
There are two types of restraint systems that
face the child toward the front of the vehicle. The
most commonly used for children who are just
being turned around is the forward-facing convertible (FFC) (figure 11A), because most children are already using these facing rearward. The
other type, which will be referred to here as a combination CR/booster (CR/B) (figure 11B), can only
be used facing forward and combines features of
a child restraint and a belt-positioning booster, to
be discussed later. Both types of forward-facing
child restraints (FFCRs) are currently limited in
the U.S. to restraining a child weighing less than
18 kg (40 lb), which corresponds to children in
anywhere from their second through seventh
year.124 Other effective limits on use include the
height of the shoulder strap routing slots, which
need to be above the child’s shoulders to effectively limit head excursion, and the height of the
back, which should be above the child’s ears to
protect against rearward bending (extension) of
the neck.
Both FFCR types are anchored in place with a
seatbelt or LATCH attachments. In addition, many
U.S. models made before September 1999, all U.S.
models made after that date, and all Canadian
models are equipped with top tether straps to be
anchored rearward from the CR. These straps significantly reduce the forward motion (excursion)
of the child’s head and stretching forces (tension)
on the neck, discussed further below. The addition of a tether strap, particularly to the taller combination CR/Bs, can extend the usability of these
systems for older, heavier children. This capability is currently only allowed in Canada, but consideration is being given to allowing it in the U.S.
as well (64 FR 36657).
Harnesses and Shields
Convertible child restraints have one of three
internal restraint configurations: a 5-point harness,
a tray shield with shoulder and crotch straps, or a
T-shield with shoulder straps (figure 9). The restraint configuration of the CR/B usually incorporates the 5-point harness to make the conversion to the booster mode easier. Although all of
these systems perform well in crash tests, and none
stand out as less effective in accident data,55 differences among them should be noted.
The original strap arrangement in early child
restraints was the 5-point harness, which was patterned after military and racing harnesses. There
is a strap over each shoulder, one on each side of
the pelvis, and one between the legs. All five come
together at a common buckle. The function of the
crotch strap is to hold the lap straps firmly down
on top of the thighs, and thus it should be as short
as possible. Because the crotch strap is merely a
lap-strap positioning device, the primary lower
torso restraint is still the combined lap straps. Although simple and effective, early 5-point harness
systems were difficult to adjust and buckle around
a squirming child, and complaints about twisting
and roping of the nylon webbing straps continue
today. Easier means of adjusting 5-point harnesses
have since been developed, however, and are now
incorporated into many models. Some manufacturers have addressed the roping problem by using more expensive polyester webbing, and one
has also gone from the usual 38 mm to 50 mm
webbing width as well.
In late 1979, a design appeared
that replaced the lap portion of the
harness with a padded tray-like
shield. The shoulder straps were
attached to the shield, which kept
them from twisting, and the shield
was held down by a crotch strap
and buckle. This design responded
to parents’ initial but erroneous
perception, held over from early
nonrestraining armrests, that
“something in front” of the child,
besides harness straps, was safest. 123 Other manufacturers
quickly followed suit. From a restraint theory point of view, the
tray shield, which is not usually
covered with energy-absorbing
Figure 11. Forward-facing child restraints: (A) forward-facing
padding, is not the best surface for the head to
convertible, (B) combination child restraint/booster as FFCR.
hit, and this contact is more likely the shorter the
child and the looser the harness. In a test series
with a 12-month size dummy, peak head accelthe pelvic breadth, and lateral restraint provided
eration was 35% higher for tray shield restraints
by lap straps is also lost. Another concern is that
than for 5-point harnesses,116 and at least one
the throat of a small child may be injured from
child, weighing 8.6 kg (19 lb), is known to have
contact with the top of the shield during a crash,
received a fatal head injury from contact with a
especially in the forward-facing position. In the
tray shield.21
12-month-dummy series, neck force was 40%
In the early 1980s, a Japanese manufacturer
higher for T-shields than for 5-point harnesses,
developed another variation on the 5-point harand the pubic load measured with T-shields was
ness that incorporated a retractor on the shoul2.7 times higher than that measured with 5der straps. These straps were attached to a flat
chest-shield with a relatively rigid stalk, which
in turn attached to the child restraint between the
Neck Injury in Forward-Facing Child Restraints
child’s legs. Eventually, similar designs began
Facing a child forward for travel is not withto appear on the U.S. market, some with autoout risks, but too often it is seen by parents as a
matic retractors and some with manual strap adgoal to be achieved as soon as possible. This goal
justers, and were referred to as T-shields. Alis inappropriate, but misinformation and lack of
though ease of adjustment and one-handed opunderstanding about the crash environment and
eration of the T-shield offer convenience for parchild physiology have been difficult to overcome,
ents, there are some theoretical problems with
even within the medical community. There has
this restraint configuration. Because the length
long been a concern in bioengineering literature
and angle of the stalk is fixed, it is not possible
that a child’s cervical spine could be pulled apart
to adjust the shield to fit close to a small child’s
from the force on the head in a crash when the
body or low across the pelvis. As discussed earshoulders are held back.15 One popular misconlier, a loose-fitting restraining system does not
ception, however, is that muscle strength can overcouple the occupant tightly to the crushing vecome this force, and that a child who can hold up
hicle, and higher forces on the body will result.
its head and sit erect is “strong” enough to face a
In addition, the lower torso restraint of the lap
frontal crash.
straps is now replaced by a narrow vertical stalk
In a 50 km/h (30 mph) crash with a 25-g pasthat concentrates impact forces at the center of
senger compartment deceleration, for instance, the
the pelvis rather than spreading the forces across
head of a forward-facing adult or child may expeUMTRI RESEARCH REVIEW
rience as much as 60 or
70 g, because the
occupant’s head stops
later and more abruptly
than the vehicle’s floor
pan. Even the strong
neck muscles of military volunteers make
little difference in such
an environment. Rather
it is the hardness of the
vertebrae, in combination with the tightness
Figure 12. Twenty-month-old child, weighing
of the connecting liga13 kg, in a rear-facing child restraint.
ments, that determines
whether the spine will hold together and the spinal cord will remain intact within the confines of
the vertebral column.42,107
Adult cervical spines can withstand severe tensile forces associated with decelerations up to 100
g,76 and failure is nearly always associated with
fracture. On the other hand, the immature vertebrae of young children consist of both bony segments and cartilage, and the ligaments are loose
to accommodate growth.63,84 This combination allows the soft vertebral elements to deform and
separate under crash conditions, leaving the spinal cord as the last link between the head and the
torso. According to Huelke et al.,42 “In autopsy
specimens the elastic infantile vertebral bodies and
ligaments allow for column elongation of up to
two inches, but the spinal cord ruptures if stretched
more than 1/4 inch.” Mathematical models of pediatric spines (age 1, 3, and 6) subjected to various types of loading indicate that, compared to
adult spines, the anatomical and material proper-
ties of immature spinal elements make them much
more flexible than would be predicted by relative
size alone.62 Stalnaker notes that the risk of spinal
cord injury in children increases with crash severity and decreases with age.107
Accident experience has shown that a young
child’s skull can be separated from its spine by
the force of a crash,27 the spinal cord can be severed,41 or the child may live but suffer paraplegia
or tetraplegia due to the stretched and damaged
cord.67,113,122 Eleven cases studied in depth were
included in the two 1993 reports. All children with
severe injuries were 12 months old or younger,
whereas others who suffered less severe injuries,
such as C2 odontoid fractures, were over 18
months. All crashes were frontal (10 to 2 o’clock),
with velocity changes ranging between 24 and 60
km/h (15 to 37 mph). It must be emphasized that
these injuries appear to be rare, although there has
been no recent attempt to estimate the risk of occurrence. Because of the potentially severe consequences, however, and the relatively simple
countermeasure to such injury among the youngest children, it makes sense to keep them restrained
rear-facing as long as possible (figure 12).
Tethers and Crash Performance
In a forward-facing child restraint, a tether can
be used to anchor the top of the CR directly to the
vehicle and thereby virtually eliminate any pitching motion in a frontal crash. Figure 13 shows a
crash sequence comparing the performance of the
same model of CR tethered (near side) and
untethered (far side) in a 48 km/h crash test with
a 3-year size dummy. Note the difference in head
excursion, or the distance the dummies' heads
travel forward. In an actual crash, a child would
be much less likely to experience head contact
with the interior. Among children injured in
FFCRs, head and facial trauma predominate.55,58
Head contact while the neck is in tension, although
again a rare occurrence, can also generate vertebral fractures and dislocations, as well as spinal
cord injury, by suddenly stopping the free motion
of the head and putting significant compressive
and shear loads on the neck.76,107 Reduction of head
excursion and elimination of head contact is therefore as important for avoiding neck injury as it is
for reducing head and facial injury in children.
Laboratory testing with a variety of instrumented dummies has shown that other injury parameters, including head acceleration and neck
loading, also decrease in tethered FFCRs compared to nontethered ones in frontal crashes.14,68,69,72
The measured reductions are greater for tethers
mounted at the top of the CR, especially for the
neck tension parameter, than for those mounted
lower at the height of the shoulder strap slots. This
difference is probably related to the length and
shape of the tether routing path, the higher mount
generally taking a straighter route to the anchor.
The primary tether benefit, however, is that of significantly reduced head excursion, which occurs
with either mount location. Tethers are also beneficial in making up for suboptimal vehicle
seatbelt configurations and seating contours,57 and
they give parents a needed sense of installation
In New South Wales, where CR usage is high
and FFCRs are routinely tethered, child injuries
tend toward minor lacerations or bruising from
flying debris, grazing of adjacent structures, or
webbing contact.39 Serious neck injuries without
head contact or gross misuse seem to be nonexistent.
Side Impact Protection
Approximately twice as many crashes with a
child fatality are frontal compared to lateral, but
side impacts are nearly twice as likely to result in
a child fatality as frontal impacts, regardless of
restraint status or seating position.12,66 The net result is that the number of children killed in each
type of crash is about the same. There are also
indications that the relative risk in side impacts
may be even greater for children in FFCRs, largely
because these restraints are so effective in frontal
crashes.98 Again, however, head and facial injuries predominate for children in FFCRs in lateral
Only two countries, Australia and New
Zealand, currently evaluate child restraints in a
side impact, and their test, which is conducted on
an open seat, does not reflect the injury-causing
intrusion environment in the real world.66 Efforts
are therefore underway to develop a test procedure that mimics the angle, speed, and shape of
side-door intrusion found to be associated with
serious and fatal injury to restrained children.65,96
Although not conducted with a definitive test, preliminary evaluations of alternative CR anchor systems clearly indicate that a rigid installation to
the vehicle and deep side wings containing energy-absorbing padding are critical features of an
effective CR in side impact.13,56,69 Deep side support and padding are more important on the struck
side, while rigid anchors make more difference
on the nonstruck side. Again, a top tether, which
Figure 13. Crash sequence
showing the relative performance
of a tethered (near side) vs. an
untethered (far side) child restraint.
is not a rigid attachment, seems to make little difference to side-impact performance compared to
the benefit of rigid vs. belt-based lower attachments.
Airbags and Forward-Facing Restraints
Children properly restrained, facing forward,
and well away from the airbag should be at no
greater risk of injury from deployment than a
belted adult in the same seating position. Airbagrelated injuries may include skin or corneal abrasions from high-speed fabric impact.99 It is unlikely, however, that the CR-restrained child will
derive any added benefit from the airbag. As of
June 2000, there were 49 fatalities among children age 1 through 5 related to passenger airbag
deployment, but none were restrained in a FFCR.85
(Four children were buckled in CRs that were not
secured to the vehicle, 6 were in belts alone, and
39 were unrestrained.) This is not to say that the
configuration is risk-free. It is still important to
maintain as great a distance as possible from the
airbag housing, and this distance is limited by the
forward positioning of the child by the CR itself,
even in the most rearward vehicle seat position.
Misuse of Child Restraint Systems
Even with the variety and widespread availability of good child restraint systems, there is still
a challenge to get them used and used to maximum advantage. Although suboptimal use in lowseverity impacts will not likely result in child injury, proper use may make the difference between
life and death in high-severity crashes.90 Misuse,
intentional or not, can compromise or even negate the protective features designed into a CR.
Many such misuses have already been mentioned,
and many are a matter of degree. A large observation study in four states found that about 80% of
child restraints were not being used as intended,22
but fortunately the majority of these misuses
would not have rendered the restraint ineffective.
Clearly a failure to anchor the CR or to harness
the child is about the same as nonuse, but there
are many other opportunities to do the wrong
thing. It is therefore important for parents and field
technicians to understand the concepts, so that they
will know in which direction to aim when perfection cannot be achieved.
With an RFO infant restraint, trying to use it
facing forward can result in dangerous loading and
possible ejection, because there is no tested path
for the vehicle belt. Although an RFC provides a
method for forward-facing installation, the infant’s
spinal cord is still at risk. Installing either type of
RFCR in a seat with an airbag carries a very high
risk of death in a crash. Shoulder straps routed
above a larger rear-facing child’s shoulders may
allow ramping above the top of the restraint, with
possible head-contact or neck-compression injury.
Smaller babies may not reach the top, but the additional movement allowed by high strap routing
or a loose harness can induce higher loads on the
shoulders or may result in ejection in side or
rollover crashes. Use of a strap clip at midchest
will keep snug straps in place, but it may not make
up for a slack harness in a crash. Finally, the back
angle of an RFCR may be the most important factor in its performance and is probably the least
understood. If too flat, it cannot restrain; if too
upright, a newborn may be unable to breathe.
There is no ideal angle for all cases. Rather the
RFCR should be as upright as possible, while ensuring that the child’s head lies back against the
restraint surface, but never more than 45° from
vertical. A secure installation is also important,
and the extra restraint gained by resting an RFCR
against the back of the seat in front is a possible
advantage of a rear seat with limited space.
Forward-facing restraints are most dependent
on harness tightness and fit, as well as tight coupling to the vehicle. With head injuries being the
most common and the most life threatening, the
goal is to keep the head from hitting anything.
Loose straps or a loose installation will allow the
child greater movement toward vehicle interior
surfaces and generate higher loads on the child
when the system finally pulls up tight. The improvement offered by a tether strap is also degraded by slack. A strap clip at midchest can help
keep the harness in place prior to impact, but it
should not be considered a substitute for a snug
fit. One-piece clips slide down the straps as the
child presses forward or may break if sliding is
restricted, and many two-piece clips are designed
to separate under low loads for extrication purposes. Using either clip instead of the buckle to
secure the harness, or routing the straps under the
child’s arms, could result in ejection or serious
injury to thoracic and abdominal organs. Using
shoulder strap slots below the child’s shoulders
effectively introduces slack in a crash, as the
child’s torso bends forward and curls under the
straps. Moreover, some lower slots are not adequately reinforced to withstand the forward-facing load.
Problems with nonlocking latchplates on
seatbelts led to the development of the locking
clip, which can be used to eliminate webbing slippage from the shoulder to the lap portion of the
seatbelt to hold the CR tightly in place. Although
this clip improves the installation in many cases,
it was never intended to withstand severe bending forces during a crash. If it is incorrectly attached to the belt on the outboard side of the CR,
rather than next to the latchplate, the clip will
likely deform and release the belts, introducing
significant slack. The benefit afforded by locking
clips in actual practice may be overrated. Anecdotal information and observations at child restraint check-up events have indicted that these
clips may be doing more harm than good, because
of their likely misapplication. Since model year
1996, seatbelts have been required to incorporate
a means of locking lap belt length when used with
a CR (58 FR 52922), but some of these systems
have not proven as effective as expected. A few
CR models include belt locking devices attached
to the restraint, but some work better than others.
The belt-locking problem is another reason for the
adoption of LATCH anchors for child restraint
Improved child restraint design and labeling
have largely eliminated seatbelt misrouting that
was common a decade ago, while new adjustment
hardware and fixed-length crotch straps have
made good fit more likely. Color coding of rearfacing vs. forward-facing features by one manufacturer is a welcome approach, and visual indicators for back angle and buckle latching provide
useful feedback to parents. Standard methods for
evaluating the potential for and consequences of
CR misuse have been finalized45,46 and should be
used by manufacturers prior to launching a new
product to make dangerous practices unlikely to
occur. In the end, however, children are still dependent on parents or caregivers to take the time
to fasten the harness, adjust it snugly, and secure
the restraint facing the right direction tightly to
the vehicle.
Children with Special Needs
Children with special medical needs also require effective restraint. The same general principles apply, but sometimes their implementation
must be different. Car beds for fragile infants is
one example, but there are other systems that have
been developed for children in hip and body casts,
those with tracheostomies or muscle tone abnormalities, and children confined to wheelchairs.110
The American Academy of Pediatrics6 and the
National Easter Seal Society are sources for additional specific information.
When a child can no longer fit into a convertible or other FFCR, the next step is a booster.
Boosters are not restraint systems by themselves,
but rather positioning devices that depend entirely
on the vehicle belts to hold the child and the
booster in place. Thus they facilitate the transition between a child restraint and seatbelts. Results emerging from a large-scale crash surveillance system focused on children show that
seatbelts alone are much less effective than FFCRs
or belts used with boosters.129 There have been
two different types of boosters available in the
past, but only one is now considered to provide
adequate crash protection.
Belt-Positioning Boosters
A belt-positioning booster (BPB) raises the
child so that its body geometry is more like that
of an adult and helps route a lap/shoulder belt to
fit that body size (figure 14). It should have small
handles or guides under which the lap belt and
the lower end of the shoulder belt are routed 16,111
(figure 14A), but some merely have a depression
or slot for the belt path. The guides function much
like a crotch strap, holding the lap belt low and
flat across the child’s upper thighs, while the inboard guide also pulls the shoulder belt toward
the child and makes its angle more vertical, so
that the belt crosses the center of the child’s chest.
Many boosters have high backs that not only give
the child rear head support on older-vehicle seats
with low backs but also have upper belt guides to
optimize the location of the shoulder belt (figure
14B). A clip on the end of an adjustable strap acUMTRI RESEARCH REVIEW
Figure 14. Belt-positioning boosters:
(A) backless booster, (B) high-back booster.
complishes this with some backless boosters as
well. The cushions of both booster types are also
shallower than the vehicle seat cushion, so a
child’s knees can bend comfortably at the edge.
This encourages a child to sit up straight with its
back flush with the seatback.61
Booster cushions were developed in Sweden
and Australia in the mid-1970s to allow children
to take advantage of the vehicle’s built-in upper
and lower torso restraint,82,92 and they have been
used there and elsewhere successfully ever since.
Although several models were manufactured in
the U.S. in the early 1980s, they soon disappeared
again because lap/shoulder
belts were not generally available in rear seats where children sat, and parents were
therefore required to install a
tether anchor for a special Yharness to provide full protection. Even after outboard rearseat lap/shoulder belts became
standard equipment for passenger cars with model year
1991 (54 FR 46257), it took
another four years for federal
rules to be changed to allow
boosters to be certified for use
with lap/shoulder belts (59 FR
37167). In the interim, the
market shifted to shield boosters, discussed below, although
the shields of later designs could be removed to create BPBs.
It is only recently that BPBs have
seen a resurgence. These are primarily
of the high-back design, because many
are sold as combination CR/Bs and the
public perceives them as safer than
backless models. The high back is only
useful, however, with low vehicle
seatbacks, unless there is also a side
structure to provide some head support
for a sleeping child or possibly side head
protection. Compared to backless boosters, high-backs position the child several inches closer to forward surfaces,
are more expensive, and may be uncomfortably upright for long trips. Because
of the back, they are subject to a weight limitation of 4.4 kg (9.7 lb) to avoid injurious loading
of the child into the belt by the booster itself. This
limit is 10% higher than the heaviest booster in
Sweden in 1990,114 but there is no evidence from
crash experience that it is too high.
Shield Boosters
Shield boosters (figure 15) were designed to
be used in seating positions with only a lap belt,
which was the typical rear seat environment in
American cars until the last decade and still is for
some segments of the population, including many
young parents. In most versions, the lap belt went
across the front of the shield, transferring the load
against the belt to a wider, somewhat flexible surface on the child’s abdomen. The low shield provided virtually no upper torso restraint. The primary value of this type of booster was that it raised
the child up for better visibility and provided a
buffer between the child and an ill-fitting lap belt
that might ride up around the child’s waist.
The original shield booster, which had a higher
shield than later models, was developed in the mid1960s.37 The high shield acted much like an airbag,
restraining the head and upper torso in a frontal
crash while deforming to absorb energy. It sat at a
fixed distance from the vehicle seatback and was
thus comfortable for the child, although it might
not be snug against a slender child’s body. From a
parent’s point of view, the restraint was considered easy to use if left buckled in place but was
cumbersome to move from one vehicle to another.
Some parents also objected that the high shield
blocked the child’s view.
The lower shield, however, concentrated the
impact forces on the upper abdomen, rather than
spreading them over the entire front of the child’s
torso, and early laboratory tests with a specially
instrumented dummy indicated that these abdominal forces might be excessive.79 In crash tests, the
child dummy typically wraps around the low
shield until the head contacts the legs or the front
of the booster. In contrast, an FFCR long available in Europe, which has a flat but deep shield
made of energy-absorbing materials, combines the
performance of the high shield with the consumer
acceptability of the low one.
The lack of upper torso restraint could not be
solved by using a lap/shoulder belt with a shield
booster unless the shield was removed, as most
eventually allowed. The shield itself usually
pushed the shoulder belt up and away from the
child, making its angle worse with respect to the
child’s body. Moreover, routine impact tests indicated that, when the upper torso was held back by
the shoulder belt, the lower torso moved forward
and tended to slide under the shield, which in turn
could rotate out from under the belt, depending
on its method of attachment.120
Shield boosters are no longer considered appropriate crash protection for children. Crash investigations have documented ejections, excessive
excursions, and shield-contact injuries in rollover,
side, and frontal crashes, resulting in severe head,
spinal, abdominal, and extremity injuries.74,104,107,127
Marriner et al. have also duplicated ejections in
Figure 15. Shield booster
(no longer recommended).
field experiments, and Meissner et al.77 have demonstrated substantial forward excursions with
dummies in severe crash tests compared to the
BPB alternative. Guidelines from the American
Academy of Pediatrics recommend against shield
boosters for children under 18 kg (40 lb).7 In addition, changes to Federal Motor Vehicle Safety
Standard (FMVSS) 213 that require testing with
a 6-year-size dummy effective September 1996
have made it virtually impossible to reliably meet
both its head excursion and acceleration criteria
in order to certify a shield booster for children
over 18 kg.
The Lap Belt Dilemma
Until this year, there were no restraint systems
that could legally be sold in the U.S. mass market
for children over 18 kg that did not depend on a
lap/shoulder belt for upper torso restraint. If a family had a vehicle with only lap belts in the rear
seat, or had more children over 18 kg than seating
positions with lap/shoulder belts, there was no
simple solution for providing crash protection
beyond the lap belt alone, which has well-understood and documented risks.64,90,91
The use of a BPB with only a lap belt is not
recommended, even when that lap belt fits poorly.
Children under 18 kg should be restrained in a
CR. For those over 18 kg, the risk of head impact
and consequent head/neck injury in the absence
of upper torso restraint increases the more the child
is raised off the vehicle seat. This is due primarily
to the longer belt that is needed to go around both
child and booster,125 and can be exacerbated by
compressible booster material.39 With respect to
prevention of head contact, it is better for a child
to sit directly on the vehicle seat when only a lap
belt is available than to sit on a BPB.
A new entry into the U.S. market can restrain a
child up to 27 kg using only a lap-belt installation. This is achieved primarily by a low seated
height and associated center of gravity, which is
suitable for larger children (figure 16). Early products were only available with tray-shield restraining systems, but a 5-point harness model is now
available, which should be widely acceptable for
use with children over 18 kg, especially in older
vehicles or with larger but behaviorally less mature children.
Canada Motor Vehicle Safety Standards
(CMVSS) allow FFCRs to be certified for chilUMTRI RESEARCH REVIEW
dren up to 22 kg (48 lb) using a
top tether strap, since all CRs
may use this device to meet
CMVSS 213 (SOR/98-159).
U.S. regulations, however, do
not. This prohibition also precludes selling a tethered Y-harness with a BPB, which was legal in the early 1980s. A petition requesting NHTSA to
modify U.S. regulations to allow certification of tethered
FFCRs for children weighing
over 18 kg, or to determine
other solutions to this problem,
has been under consideration
for nearly 3 years. 119 In the
Figure 16. Child restraint system
meantime, the best alternatives
with low center of gravity for
may be to install lap/shoulder
children up to 27 kg.
belts in place of rear-seat lap
belts for use with a BPB, or to restrain one child
in front with the lap/shoulder belt and a BPB. As
last resorts, use the lap belt alone, if it will stay
down on the lap, or use an old shield booster.
The term seatbelt refers to either a lap/shoulder combination or a lap belt alone. Although the
former has become standard equipment in most
vehicles, there are still many on the road with only
lap belts in rear seats. Vehicle seatbelts are designed primarily with adults in mind, and geometric factors may make good fit difficult for children. Seatbelts are not, however, inherently dangerous, even for young children,36,38 and should
be used when a more appropriate restraint system
is unavailable. Seatbelts are part of a continuum
of restraint systems with varying levels of effectiveness for children. In general, more restraint is
better than less, and good fit is important for effective restraint performance.
Unfortunately, poor fit of seatbelts often leads
to misuse, with shoulder belts placed behind the
back or under the arm,29,77 which degrades their
performance. Even so, statistical analysis of a large
Canadian data file indicates that seatbelts reduce
fatalities and serious injuries of children age 4
through 14 by 40%.17 A U.S. injury data analysis,
however, confirmed that restrained children age
6 through 12 are not as effectively protected as
those through age 5,60 and data from an analysis
of 1994 fatal crashes showed a similar proportion
of fatalities among children age 5 through 9 restrained by seatbelts as among those who were
Child Size and Belt Fit
Good fit of a lap belt is as low as possible on
the pelvis, touching or even flat across the thighs.
A shoulder belt should cross the chest at
midsternum and lie flat on the shoulder about halfway between the neck and arm (figure 17). Such
fit is dependent primarily on the sitting height of
the occupant, and suitable occupant size varies
considerably from one specific belt and seat combination to another. Measurements and observations of 155 children age 6 through 12 done by
Klinich et al.61 indicate that a child needs to have
a sitting height of 74 cm (29 in) to comfortably
and effectively use most lap/shoulder belts, a result consistent with the sitting-height recommendations previously made by Stalnaker.106 To assist
parents in judging their child’s size, Klinich et al.
also included guidelines for standing height of 148
cm (58 in) and a clothed weight of 37 kg (81 lb),
but age was not considered a useful indicator because of the wide variations in anthropometry
within each age group. The study also found that
3-point belts fit the taller, thinner subjects better
than the shorter, chubbier subjects of the same
weight. Each child should therefore be individually evaluated in a particular seat and belt system
to determine whether a BPB is still needed or the
seatbelt can be used alone.
To achieve the best fit, the child should be sitting fully upright with its pelvis as vertical and as
far back into the seat as possible, and preferably
with its feet touching the floor. This will help place
the lap belt in front of the pelvic bone below the
anterior-superior iliac spines and will minimize
the possibility of the belt sliding up and intruding
into the soft upper abdomen. The lap belt must
not be placed or be allowed to ride up around the
waist. Klinich et al.61 found that children whose
upper legs were too short for their knees to bend
over the front edge of the seat tended to slouch
their pelvises forward and slide under the lap belt.
If an erect seated posture cannot be achieved, or
if the shoulder belt crosses the throat, the child
needs to use a BPB.
Shoulder belts that touch the side of the neck
are not likely to cause injury unless they are very
loose.8,19,89 Although individual cases of vertebral
and spinal cord injury are reported in the medical
literature, there is usually insufficient information
to determine crash and restraint conditions. Until
an independent evaluation of these cases has been
done, similar to that for the forward-facing infant,
the actual mechanism of injury and guideline for
prevention are largely speculative. In any case,
the shoulder belt should not be routed behind the
child’s back, because the fit of the remaining lap
portion will not be the same as a lap-only belt,
and the belt will likely ride too high on the inboard side. Finally, the shoulder belt should never
be routed under the arm, because the resulting belt
forces on the side of the thorax are known to result in serious internal injuries in a crash.29,108
Shoulder Belt Positioners
Various unregulated devices have appeared on
the market in the last several years to pull a shoulder belt away from a short occupant’s neck. Although possibly useful for a small adult, who
might need only a minor modification of the belt
geometry, they are not suitable for children. Most
of these devices connect the shoulder belt to the
lap belt in front of the body in some fashion,
thereby changing and often degrading the performance of the original belt system.109 Effects include increased head and chest acceleration and
increased roll of the upper body out of the shoulder belt. In addition, some devices made of plastic break on impact, and others made of metal bend
significantly under load. Others made of soft materials may be effective in pushing the belt away
from the neck but can also be easily misused to
push the shoulder belt onto the arm. Most important for children, however, they do nothing to
improve the positioning of the lap belt on a small
body and may actually lift it higher, and the
slouching problem with short legs remains. Shoulder belt positioners should not be used in place of
The NHTSA test series109 used 3-year, 6-year,
and 5th-percentile female dummies.81 Although
there were only minor variations in performance
in most tests with the 6-year dummy, compared
to those with the 3-year and small female dummies, and not all degradations would be considered failures, these results should not be consid-
ered a definitive endorsement.
The test procedure was limited
in realism by the nearly ideal
test bench, belt geometry, and
dummy positioning used, and
the stiff thoracic and spinal
structures of the child dummies
virtually precluded their sliding
under the lap belt. If these devices are to be regulated in the
future, it will be necessary to develop performance criteria beyond those in the current child
restraint standard (49 CFR
571.213), to use more sophisticated dummies, to use realistic
seat cushion shapes and belt anchor geometries, and to incorporate a belt fit criterion that ensures the lap belt will be properly located on the upper thighs.
Figure 17. Good lap/shoulder belt fit.
A provision in the European
child restraint regulation, which says “devices utilizing a lap strap must positively guide the lap
strap to ensure that the loads transmitted by the
lap strap are transmitted through the pelvis” (E/
ECE/324/Reg44/6.2.2), has been interpreted to
include not only boosters but other belt-positioning devices as well. Few, if any, of the current
shoulder belt positioner designs would qualify.
Lap vs. Lap/Shoulder Belts
Restraint theory leads to the conclusion that
lap/shoulder belts would be better for children,
even if fit is not optimal, than a lap belt alone.
This assumption was made by Johnson et al.48 for
an analysis of police-reported data on children
over age 4, but the data did not show a significant
difference in injury reduction by belt type. Other
analyses with more detailed usage and injury information also found no significant differences in
overall injury severity and rates among children
in different types of belts.2,3,29,38 Head and facial
injury patterns were similar, although Henderson
et al. found that the injury source differed by seating position as well as by belt type. Halman36
looked at the Injury Severity Scores (ISSs) of 200
school-age children in a Transport Canada data
base and determined that there was no statistical
difference between those in rear-seat lap belts vs.
front-seat lap/shoulder belts, and that both types
of restraint systems reduced ISSs for children
comparably to the reduction for adults.
A complicating factor in past comparisons of
lap vs. lap/shoulder belt effectiveness was that
seating position (outboard vs. center, front vs. rear)
was necessarily mixed in with belt type. Data
analysis by Braver et al.12 showed a 32% reduction in fatalities for children 5 through 12 in rearseat lap belts compared to those in front-seat lap/
shoulder belts in pre-1988 cars, but an even greater
reduction (44%) when lap/shoulder belts were
compared for both front and rear in newer cars.
(The 95% confidence intervals overlap, however.)
A reduction of 24% is also given for all restrained
children in the rear-center vs. the rear-outboard
positions. These results imply some benefit from
the lap/shoulder belt that may be masked by its
outboard location and/or front seating position.
When comparing only abdominal and lumbar
spine injuries, ten years of Australian data indicated the relative risk for children in rear-seat lap
belts was twice that of rear-seat lap/shoulder
belts.64 The Gotschall et al.29 series showed a similar occurrence of soft tissue injury in the abdominal region by belt type, but the lumbar spine fractures were limited to the lap-belted children. Included in the latter were children who had put the
shoulder belt of the 3-point system behind their
backs. From these studies, it might be concluded
that the pelvis can slide under either configuration, but that the upper torso must be thrust over a
high lap belt to break the spine.
The question of fatality reduction effectiveness
of rear-seat lap vs. lap/shoulder belts has recently
been addressed in an extensive double-pair analysis by Morgan,83 in which children of age 5 through
14 were included and evaluated separately. The
conclusions for rear-outboard occupants in this age
group are that lap-belted children were 38% less
likely to die than unrestrained children, while lap/
shoulder-belted children were less likely by 52%.
The lap/shoulder belt was found to reduce fatalities 26% over lap belts alone for children 5 through
14 in all crashes and 31% in frontal crashes, and
children derived more relative benefit from the
lap/shoulder belt than did the adult groups. Further analysis with supplemental cause of death
data indicated that both types of belted children
were somewhat more likely to receive abdominal
injuries than unrestrained children, but the increase
for the adult groups in lap belts was much greater.83
Finally, both belt systems markedly reduced fatal
head injuries, but these were still twice as likely
among lap-belted than lap/shoulder-belted children (64 FR 36657). This study makes it clear that
shoulder belt use is very beneficial for older children.
Airbags and Seatbelts
Children in seatbelts may be at greater risk of
injury from airbags than their younger siblings restrained in FFCRs, because the former are able to
lean forward in their shoulder belt or even put the
belt behind their back. This behavior may place
their head in the path of the deploying airbag or
allow their upper body to be thrown forward during precrash braking. Among the 28 children age
6 through 11 who were killed by passenger airbag
systems as of June 2000, five had the shoulder
belt behind their back, one was leaning forward
in his belt, and the cases of another two in lap/
shoulder belts are still under investigation. The
other 20 were unrestrained.85
The consistent and proper use of restraint systems by infants and children in passenger vehicles
can prevent hundreds of deaths and thousands of
injuries each year. Infants require the most special treatment, with restraint systems designed to
apply crash forces to their backs or the full length
of their bodies. Children over 1 year also benefit
from specially designed restraints that snugly conform to their small body shape, while providing
elevation so that they can see the world around
them. Seatbelts can provide good restraint for
older children, particularly when adapted to their
body size by a booster, and provided that attention is paid to good belt positioning and fit. It is
important to understand both the theory behind
the design of restraint systems and how this theory
has been applied to be able to evaluate child restraint performance in a crash, to develop improved restraint systems, and to provide informed
guidance concerning child restraint selection and
Kathleen Weber is project director of the Child Passenger Protection Research Program in the University of Michigan Medical
School, Pediatric Surgery Section.
She works with manufacturers, consumer groups, and government
agencies to evaluate and improve
the effectiveness of all types of child
restraint systems. Ms. Weber’s first research
study concerned the comfort and convenience
of restraint systems for infants, but she later
changed her focus to crash testing. Ms. Weber
chaired the Society of Automotive Engineers
committee on the interaction of child restraint
systems with airbags, and she was instrumental in bringing to public attention the dangers
of airbags to restrained infants. She has also
served on two Blue Ribbon Panels advising the
government on child restraint compatibility
with vehicles and on restraining older child pas-
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numerous papers on such topics as
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Hutchinson Award for contributions resulting
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