Child Car Restraints Review RRCGB 2015 Update

Child Car Restraints Review RRCGB 2015 Update
CHILD RESTRAINT SYSTEMS
ROAD SAFETY OBSERVATORY: VEHICLES
Other relevant syntheses to be consulted:
 Seat Belts
 Advanced Vehicle Systems - Collision Protection
 Crash Mitigation and Collision Avoidance
Keywords:
“Child car restraints”, “Child car seats”, “child seats”, “Child restraints”, rear-facing
baby seats”, “Rearward-facing baby seats”, “Forward-facing child seats”, “Booster
seats”, “Booster cushions”
1
KEY FACTS
 In 2015, 11 children under 12 years old were killed while travelling in cars in Great
Britain, 200 were seriously injured and there were 5,092 child car casualties
(reported to the police) in total. (RRCGB 2015, DfT, 2016)
 Adult Seat belts do not fit children correctly, and so do not offer the same level of
protection as they do for adults (although they are far better than using no restraint
at all). Therefore, children need to use child car restraints, not just seat belts on
their own.
 Using an appropriate child car restraint is highly effective in reducing the risk of
death or injury for child car passengers in a crash. Children using an appropriate
child restraint are significantly less likely to be killed or injured than unrestrained
children, and are also less likely to be killed or injured than children using adult
seat belts.
In the UK, children (with very few exceptions) in cars, vans and other goods vehicles
must travel in an appropriate child restraint from birth until either they are 135cm
(4’5”) tall or have reached the age of 12 years (whichever comes first). Child car
restraints must be approved to either UNECE Regulation R44 (Child Restraints) or
UNECE Regulation 129 (Enhanced Child Restraints).
Rearward-facing Child Restraints
 Babies and infants need to be carried in rearward-facing baby seats. This reduces
the risk of death or injury in a crash by 90% compared with being unrestrained. It
is common in the UK for infants to be moved into forward-facing child seats when
they reach 13kgs in weight, around 1 year old.
 However, research in Sweden indicates that children are safer in an appropriate
rearward-facing seat until they are 3 or 4 years of age, although this was
compared with being in a booster seat, rather than a forward-facing seat with an
integral harness, which is more common in the UK for this age group.
Forward-facing Child Restraints
 Research in the USA found that the risk of serious injury was 78% lower for
children in forward facing child restraints than for those in seat belts. Another USA
study concluded that the odds of injury were 81.8% lower for toddlers in child
seats than for toddlers wearing seat belts.
2
Booster Seats and Booster Cushions
 Swedish research concluded that children aged 4 to 10 years who used a booster
seat were 77% less likely to be injured in an accident compared with an
unrestrained child. USA research found that the odds of injury were 59% lower for
4 to 7 year old children in booster seats than in seat belts.
 Analysis of 10 years of data in the United States showed that 4 to 8 year old
children in booster seats were 7.7 times less likely to suffer moderate to serious
injuries in frontal and side impacts than unrestrained children, They were also
13.3 times less likely to suffer moderate to serious injuries in rear impacts and
23.6 times less likely to suffer these injuries in rollover crashes.
Risk According to Seating Position in the Car
 It is safer for children to sit in the rear of the car than in the front. The centre rear
seat is safest of all, but only if it has a 3-point seat belt and not just a lap-only belt.
Child Restraint Use
 Observational surveys in 2008 in Great Britain found that three-quarters (74%) of
1 to 4 year old children travelling in the front of cars were using a child car
restraint (a forward-facing child restraint, a booster seat or booster cushion), but
most (93%) did so in the rear.
 Older children (or 5 – 9 years) were much less likely to use child car restraints,
with only 28% doing so in the front and 43% in the rear.
Incorrect Use of Child Car Restraints
 Although child car restraints are very effective in reducing the risk of death or
injury in a vehicle crash, their effectiveness is reduced if the restraint is not being
used or fitted properly.
 Using ISOFIX child car seats may reduce the likelihood of the seat being
incorrectly fitted.
 Seats which conform to the new i-size standard are designed to provide side
impact protection and keep children rearward-facing until they are at least 15
months old.
3
SUMMARY
 Travelling as a passenger in a car is one of the main ways that children under 12
years old get about.
 In 2015, 11 children under 12 years old were killed while travelling in cars in Great
Britain, 200 were seriously injured and there were 5,092 child car casualties
(reported to the police) in total. (RRCGB 2015, DfT, 2016)
 In a collision, an unrestrained vehicle occupant continues to move at the same
speed the vehicle was travelling in until they hit something, such as part of the
vehicle’s interior. This can cause a range of injuries, including fatal ones. They
may also be ejected from the car through one of the windows.
 Adult Seat belts do not fit children correctly and so do not offer the same level of
protection as they do for adults (although they are better than using no restraint at
all). Therefore, children need to use child car restraints, not just seat belts on their
own.
 The safest way for children to travel in cars is in a correctly fitted child restraint
that is suitable for their weight and size, and in the rear of the car.
 In the UK, the law requires all children (with very few exceptions) in cars, vans
and other goods vehicles to be carried in an appropriate child restraint from birth
until either they are 135cm (4’5”) tall or have reached the age of 12 years
(whichever comes first).Child car restraints must conform to either the Regulation
R44 standard or the Regulation 129 (i-size) standard.
The Effectiveness of Child Car Restraints
 Using an appropriate child car restraint is highly effective in reducing the risk of
death or injury for child car passengers in a crash.
 Children using an appropriate child restraint are significantly less likely to be killed or
injured than unrestrained children.
 They are also less likely to be killed or injured than children using adult seat belts.
Child Car Restraints Compared with Seatbelts
 Although a child wearing an adult seat belt is far less likely to be killed or injured
than an unrestrained child, they are more likely to be killed or injured than one
using an appropriate child car restraint.
4
Rearward-Facing Baby and Infant Seats
 Babies and infants need to be carried in rearward-facing baby seats. This reduces
the risk of death or injury in a crash by 90% compared with being unrestrained.
 It is common practice in the UK for infants to be moved into forward-facing child
seats when they reach 13kgs in weight, around 1 year old.
 Research in Sweden indicates that children are safer in an appropriate rearwardfacing seat until they are 3 or 4 years of age, although this was compared with
being in a booster seat, rather than a forward-facing seat with an integral harness,
which is more common in the UK for this age group.
Forward-facing Child Restraints
 Research in the USA found that the risk of serious injury was 78% lower for
children in forward facing child restraints than for those in seat belts. Another USA
study concluded that the odds of injury were 81.8% lower for toddlers in child
seats than for toddlers wearing seat belts.
Booster Seats and Booster Cushions
 Booster seats are designed for children from about four years old until they are
large or old enough to use the vehicle’s seat belts. They aim to raise the child so
that the adult seat belt fits correctly and the child can travel in greater comfort and
safety.
 Swedish research concluded that children aged 4 to 10 years who used a booster
seat were 77% less likely to be injured in an accident compared with an
unrestrained child. USA research found that the odds of injury were 59% lower for
4 to 7 year old children in booster seats than in seat belts.
 Analysis of 10 years of data in the United States showed that 4 to 8 year old
children in booster seats were 7.7 times less likely to suffer moderate to serious
injuries in frontal and side impacts than unrestrained children, They were also
13.3 times less likely to suffer moderate to serious injuries in rear impacts and
23.6 times less likely to suffer these injuries in rollover crashes.
Risk According to Seating Position in the Car
 It is safer for children to sit in the rear of the car than in the front.
 The centre rear seat is safest of all, but only if it has a 3-point seat belt and not
just a lap-only belt.
5
Use of Child Car Restraints
 In 2008 in Great Britain three-quarters (74%) of 1 to 4 year old children travelling
in the front of cars were using a child car restraint (a forward-facing child restraint,
a booster seat or booster cushion), but most (93%) did so in the rear.
 Older children (or 5 – 9 years) were much less likely to use child car restraints,
with only 28% doing so in the front and 43% in the rear.
 Almost all of those who were not using a child car restraint were wearing a seat
belt.
Incorrect Use of Child Car Restraints
 Although child car restraints are very effective in reducing the risk of death or
injury in a vehicle crash, their effectiveness is reduced if the restraint is not being
used properly.
 Common forms of inappropriate use include using a restraint that is not suitable
for the child’s size and weight (typically, moving a child up to the next size of
restraint too soon), and common forms of misuse include using a restraint that is
not suitable for the vehicle in which it is fitted and not fitting the restraint securely.
 Two groups of children are most at risk when they are not properly restrained:
infants using forward facing child restraints when they are less than one year old,
and children using the seat belt when they should be using a forward facing child
seat or booster seat.
 Using ISOFIX child car seats may reduce the likelihood of the seat being
incorrectly fitted.
Promoting Child Car Restraint Use
 There is evidence that educational campaigns can improve child car restraint use,
especially in combination with laws mandating their use.
 As it is well established that parents often find it difficult to choose and use an
appropriate child restraint, many interventions have been devised to help parents.
Disadvantaged Groups
 Children in deprived areas may face greater risk as car passengers because their
parents are not able to afford safety equipment, such as child car restraints.
 Free or loaned child seat schemes can be effective in increasing the likelihood of
children being restrained.
 Some evidence suggests that restraint use is higher among higher social groups,
but that lower social groups can be effectively targeted.
6
Room for Improvement
 Seats which conform to the new i-size standard are designed to provide better
side impact protection and to keep children rearward-facing until they are at least
15 months old.
 The likelihood of child restraints being fitted incorrectly can be reduced by
improving the design of the restraints so they are easier to fit (eg, ISOFIX or isize) and by providing education to parents on how to choose and use child car
restraints.
7
METHODOLOGY
A description of the methodological approach to all of the research reviews in the
Road
Safety
Observatory
is
available
at
http://www.roadsafetyobservatory.com/Introduction/Methods.
This review was originally compiled during January to April 2012, and revised in July
2013. It was updated in November 2015.
The steps taken to produce this review are outlined below:
Identification of relevant research
Searches were carried out on pre-defined research (and data) repositories, as
described in http://www.roadsafetyobservatory.com/Introduction/Methods. Various
project websites, such as those of the EC CHILD, CREST and CASPER projects,
and the NHTSA ESV archives were also used.
Search terms used to identify relevant papers included but were not limited to:
“child car restraints”, “child car seats”, “child seats”, “child restraints”, rear-facing
baby seats”, “rearward-facing baby seats”, “forward-facing child seats”, “booster
seats”, “booster cushions”
The definitions of child car restraints in this review are shown in the table below.
However, different terms are used in many of the research papers. For example, in
Sweden, rearward-facing child seats include seats for children up 3 or 4 years old,
whereas in the UK, it normally refers to seats for babies up to about 1 year old. In
countries, such as the USA, the term child car seat is commonly used, and in some
of the papers it is not specified whether these refer to forward-facing child seats or
booster seats, or both, although as the age range of children is specified, it is
possible to infer which type of seat is being described.
A total of 157 potentially relevant research papers were identified. Following the
initial review, 56 pieces of research were taken forward to form the basis for this
synthesis, 10 of which were published in the UK.
Initial review of research
This primarily involved sorting the research items based on key criteria, to ensure the
most relevant and effective items went forward for inclusion in this review. Key
criteria included:
o Relevance: whether the research makes a valuable contribution to this synthesis,
for example robust findings from a hospital-based study.
o Provenance: whether the research is relevant to drivers, road safety policies or
road safety professionals in the UK. If the research did not originate in the UK,
the author and expert reviewer have applied a sense check to ensure that
findings are potentially relevant and transferable to the UK.
o Age: Priority is given to the most up-to-date titles in the event of over-lap or
contradiction, although older research papers are included because much of the
research took place as child restraints were being developed and used.
8
o Effectiveness: whether the research credibly proves (or disproves) the
effectiveness of a particular road safety initiative or intervention.
A similar search was conducted in October 2015, but limited to new research studies
that had been published in 2014 and 2015, following which 10 new studies were
added to the review, and reported casualty data was updated to include 2014 data,
the latest available at the time of the update.
Detailed review of research
Key facts, figures and findings were extracted from the identified research to
highlight pertinent road safety issues and interventions.
Definitions
Type of Child Restraint
Weight or Height Range
Group 0
0 - 10kg (22 lbs)
Group 0+
0 - 13kg (29 lbs)
Rearward-facing baby seat
i-size
Not based on weight, but child's
height must be within the range
specified for the seat
Group 0+ and 1
Combination seat (Rearward 0-18 kg (40 lbs)
and Forward-facing)
Group 0+, 1 & 2 (55 lbs)
Birth to 25 kg
Group 1
9-18 kg (20 - 40 lbs)
Forward-facing child seat
Group 1, 2 and 3
9 - 36 kg (20 - 79 lbs)
Group 2
High-backed Booster Seat
15 - 25 kg (33 - 55 lbs)
Group 2 and 3
High-backed Booster Seat
15 - 36 kg (33 - 79 lbs)
Group 2 and 3
Booster Cushion
15 - 36 kg (33 - 79 lbs)
Group 3
Booster Cushion
22 - 36 kg (48 - 79 lbs)
Approx. Age
Range
Birth to 6-9 months
Birth to 12-15
months
Up to at least 15
months
Birth - 4 years
Birth to 6 years
9 months - 4 years
1 to 11 years
4 to 6 years
4 to 11 years
4 - 11 years
6 - 11 years
The weight ranges are derived from from UN Regulation 44 (Child restraint systems),
which specify minimum and maximum weight ranges for child restraint systems. isize seats conform to UN Regulation 129, and are based on a child’s height rather
than weight.
9
Group 0 rearward baby seats, Group 0+, 1, 2 combination seats and Group 2
forward-facing seats are less common than the other types.
Many child seats cover more than one group and are adjusted as the child grows.
They may be called combination seats, extended seats or multi-group seats. For
example:
 Group 0+ and 1 seats start off rearward-facing until the baby is at least 9 kg and
are then turned forward-facing - some stay rearward facing until the child has
reached 18 kg.
 Group 0+, 1 and 2 seats (which are not very common) start rearward-facing up to
18kg and are then turned forward-facing (they can be turned forward facing from
9 kg).
 Group 1, 2 and 3 seats are forward-facing. The child uses the seat's integral
harness, or an impact cushion, until they are 15 kg and then uses the car's seat
belt, which secures the child and the seat.
 Group 2 and 3 seats are high-backed booster seats, although they can also be
booster cushions without a back. On some of the high-backed seats, the back
can be removed once the child reaches 22 kg, but it is far better to keep the back
on the seat
10
KEY STATISTICS
In 2015, 11 children under 12 years old were killed while travelling in cars in Great
Britain, 200 were seriously injured and there were 5,092 child car casualties
(reported to the police) in total. (RRCGB 2015, DfT, 2016)
Child Casualties in Cars, 2015, Great Britain1
0 - 4 years
5 - 7 years
8 - 11 years
Total*
Killed
6
4
1
11
Seriously Injured
72
51
77
200
All
1,5248
981
2,120
5,092
*Includes age not reported.
Over the five year period, from 2011 to 2015, 55 children under 12 years old were
killed in car crashes, 981 were seriously injured and there were over 25,000 child car
passenger casualties in total. However, it is not known how many of these children
were:
 Using a correctly fitted, appropriate child restraint
 Using an incorrectly fitted or inappropriate child restraint
 Using a seat belt instead of a child restraint
 Completely unrestrained
In a collision an unrestrained vehicle occupant continues to move at the same speed
the vehicle was travelling until they hit something, such as part of the vehicle’s
interior. They may also be ejected from the car through one of the windows. This can
cause a range of injuries, including fatal ones.
Seat Belts and Children
The main system for safely restraining occupants in vehicles is, of course, seat belts.
However, seat belts do not fit children properly, and do not fit babies at all. This
means they are less effective in protecting children, and in some circumstances,
could even cause injury.
Children are not simply smaller adults; they are proportioned differently, their bones
are not fully formed and their skeletal structure does not cover and protect their
internal organs in the way it does in adults. All of these things change as children
grow older, meaning that the type of restraint system they use also needs to change,
until they reach the point where the seat belts can provide the same protection as for
adults. (Burdi and Huelke, 1969, WHO, 2009)
In the UK, children must use an appropriate child restraint (with very few exceptions)
until they are 12 years old or 135 cm in height, whichever comes first. At this point
must use the vehicle’s seat belts.1 Road safety organisations advise that it is better
to wait until the child is at least 150 cm tall before using the seat belts without a
booster seat or booster cushion.
1
“Reported Road Casualties Great Britain 2015”, Table RAS30028, Department for Transport, 2016
11
RESEARCH FINDINGS
Child Restraints Compared with No Restraint
A Swedish study of 3,670 children aged 0 to 15 years, involved in car crashes
between 1987 and 2004, found that rearward facing child restraints (including rearfacing infant seats and rearward-facing child seats for children up to 3 - 4 years old)
reduced the likelihood of injury by 90% compared with being unrestrained. Booster
seats that help to position the seat belt correctly reduced the risk of injury by 77% for
4 to 10 year old children. (Jakobssen, 2005) Some of the child car restraints, such as
rearward-facing child seats for older children and integrated booster cushions built
into cars, in this study are different from the types used in the UK.
An analysis of fatal car accidents in the USA between 1982 and 1987 estimated that
child safety seats (in the USA this term often refers to child restraint systems that
have an integral harness, but not booster seats) reduced the risk of death among
infants by 69% and for toddlers by 47%. Overall, children in child safety seats were
50% less likely than unrestrained children to be killed in these fatal crashes. The
report estimated that using the car’s adult seat belts reduced the risk of death for
toddlers by 36%. It estimated that 838 children’s lives were saved in the USA by
child restraints and seat belts over that period, with the number saved increasing as
the use of restraints increased.
The report estimated that child car restraints could have saved an additional 2,349
children if all children had been using child restraints over that period, and even
more lives if child restraints were always used correctly. The report does not
distinguish between different types of child restraint (eg, rearward-facing baby seat,
forward-facing child seat, booster seat, booster cushion), but as the report covers
infants and toddlers, it is likely that very few, if any, booster seats were included.
(NHTSA, 1988)
The NHTSA report was updated in 1996 using fatal accident data for 1988 to 1994.
Compared with being unrestrained, using a child car restraint reduced the risk of
being killed in a crash by 71% for under one year olds, and by 54% for 1 to 4 year
old children in cars. In light trucks or vans, child car restraints reduced the fatality risk
by 58% for under one year old children and by 59% for 1 to 4 year old children.
(NHTSA, 1996)
A 2011 NHTSA report estimated that child safety seats had saved the lives of 9,874
children under 5 years old between 1975 and 2011. In 2011, 245 children aged
under 5 years were saved by child safety seats, and a further 51 could have been
saved if all children had been using a child safety seat that year. (NHTSA, 2013)
An analysis of 635 child passengers aged 12 years or younger who were treated in
hospital for injuries sustained in vehicle crashes found that unrestrained children
were three times more likely to be hospitalised than restrained children (21% vs.
7%). (Lee, 2004)
A study of 17,980 children under 16 years old involved in crashes in 15 states
between December 1998 and November 2002 found that the risk unrestrained
children faced was more than 3 times the risk for restrained children. (Durbin, 2005)
12
A case-control study of 129 child car passengers aged 0–11 years injured in motor
vehicle accidents in 1996 in Athens suggested that unrestrained 0 to 4 year old
children were 3.3 times more likely to be injured than restrained children. It estimated
that in Greece about two thirds of all childhood injuries from car crashes could have
been avoided by the regular use of proper child restraints. (Petridou, 1998)
An analysis of injury rates for car passengers under 15 years old in the USA in 1990
and 1991 found that 19% of children under 1 year old who were in an appropriate
restraint were injured, compared with 40% of those who were not restrained.
Unrestrained children were 1.5 to 2.5 times more likely to be injured than restrained
children. (Johnston, 1994)
An analysis of data of crashes involving child car passengers under one year old
from 2007 to 2011 in the USA found that properly restrained infants were 12.7 times
less likely to present to a trauma centre after a motor vehicle crash. However, the
likelihood of the child passenger receiving traumatic brain injuries in higher speed
crashes was similar among properly restrained and improperly or unrestrained
infants. (C Stewart et al, 2014)
Child Car Restraints Compared with Seatbelts
A USA study of 2 to 3 year old rear seat child passengers in crashes that resulted in
at least one vehicle being towed away between 1998 and 2004 concluded that the
odds of injury were 81.8% lower for toddlers in child seats than for toddlers wearing
seat belts. (Zaloshnja, 2007)
Another American study comparing the use of child restraints with seat belts by 2 to
6 year old children involved in vehicle crashes between 1998 and 2003 found that
compared with seat belts, child restraints (when not seriously misused) were
associated with a 28% greater reduction in the risk for death in children of that age
group. When including cases of serious misuse, the effectiveness was slightly lower,
at 21%. (Elliot, 2006)
A study of crashes in 15 states in America between December 1998 and May 2002
involving 1,207 children aged 12 and 47 months, seated in the rear of vehicles,
found that the risk of serious injury was 78% lower, and the risk of hospitalisation
was 79% lower, for children in forward facing child restraints than for those in seat
belts. (Arbogast, 2004)
A study of 17,980 children under 16 years old involved in crashes in 15 states
between December 1998 and November 2002 found that the risk for inappropriately
restrained (defined as using a seat belt rather than a child safety seat or booster
seat) children was almost double that of appropriately restrained children. (Durbin,
2005)
13
An analysis of fatal car accidents in the USA between 1982 and 1987 estimated that
children in child safety seats were 50% less likely than unrestrained children to be
killed, but those using the car’s adult seat belts were only 36% less likely to be killed.
(NHTSA, 1998)
When these estimates were updated in 1996, the estimates for the effectiveness of
seat belts on their own had increased to 47% in cars and 48% in light trucks or vans.
The effectiveness of child restraints had also increased from 69% to 71% for under
one year olds and from 50% to 54% for one to four year olds. (NHTSA, 1996)
Rearward-Facing Seats
A 1996 NHTSA report estimated that child car restraints reduced the risk of being
killed in a crash by 71% for under one year olds, and by 58% in light trucks or vans.
(NHTSA, 1996)
An investigation in Sweden of the effectiveness of child restraints using data from
insurance claims found that children in rear-facing child restraints were at the lowest
risk of injury. The injury risk for children aged 0 – 4 years was almost five times
greater in a forward-facing child restraint than in a rearward-facing one. While
rearward-facing seats were 90% effective at reducing injuries, forward-facing seats
in a rear outboard position were 60% effective. The forward-facing seats were much
more effective in frontal collisions than in side impacts. (Gustafssen, 1987) It is
important to note that the forward-facing seats in this study were booster seats, not
forward-facing child seats with an integral harness.
The BMJ has recommended that children should travel in a rearward-facing seat
until they are four years old because the relatively large head mass and the anatomy
of the spine of young children can lead to excessive stretching or even transection of
the spinal cord in a frontal crash when in a forward facing car seat. (Watson &
Monteiro, BMJ, 2009)
The American Academy of Pediatrics recommends that all infants and toddlers travel
in a rear-facing car safety seat until they are two years old, or they have reached the
maximum weight or height limitations of their rear-facing seat. (Pediatrics, 2011)
Evidence from Sweden shows that rearward-facing child seats (this included both
rearward-facing baby seats and rearward-facing child seats for older children)
reduced the risk of injury by between 76% and 92%. (Carlsson, 1991)
An examination of injuries suffered by children aged under 2 years who were using
child restraints concluded that “it is possible that a redesigned car safety seat (e.g.
one that would allow children to ride rear facing in the rear until 2 or 4 years of age),
would help to reduce severe head and neck injuries to child passengers” (Fuchs,
1989)
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Child Restraints for Premature and Low Birth Weight Babies
Research carried out in the United States in the 1980s raised concerns that the
rearward-facing baby seats available were not suitable for premature and low birth
weight babies who were at risk of cardio-respiratory problems when placed in a
semi-reclined position. (Bull and Stroup, 1985, and Leuschen,1986).
The American Academy of Pediatrics recommends that infants of less than 37 weeks
gestation at birth be monitored in their car safety seat before being discharged from
hospital. They recommend that a normal rear-facing baby seat be used, unless the
baby has manifested apnea (stopping breathing), bradycardia (slow heart rate), or
desaturation (low oxygen levels) when semi-reclined in a car safety seat. Infants who
have manifested such conditions in a semi-upright position should travel in a supine
or prone position in car bed (a child restraint system in which the baby lies flat;
sometimes called a ‘baby carrier’) after an observation period that is free of such
events. (Bull and Engle, 2009)
However, a Cochrane Review concluded that it is unclear whether undertaking such
a pre-discharge assessment is beneficial or harmful to preterm infants, and that
further studies are needed. The authors raised concerns that the assessments may
cause undue parental anxiety. (Piley and McGuire, 2009)
Forward-Facing Child Seats
Forward-facing child seats are designed for children within the weight range 9 to 18
kg. Most types have an integral five point harness which restrains the child in the
child seat, but some types have an impact pad instead of a harness (they are often
called ‘shield systems’).
In the United States, it is estimated that forward-facing child seats reduce the risk of
death for toddlers by 54%. (NHTSA, 1996) Further USA research found that 19% of 1
to 4 year old children involved in a collision and who were using a forward-facing
child seat were injured compared with 22% of those in a seat belt and 43% of those
who were unrestrained. (Johnston et al, 1994)
A USA study of 2 to 3 year old rear seat child passengers in crashes between 1998
and 2004 concluded that the odds of injury were 81.8% lower for toddlers in child
seats than for toddlers wearing seat belts. (Zaloshnja, 2007)
Analysis of 10 years of data in the United States showed that children aged 1 to 3
years who were in forward-facing child restraints had a low risk of injury in frontal,
side and rollover crashes compared with unrestrained children. The risk of suffering
moderate to serious injury in a rollover crash was about 10 times higher for an
unrestrained child than for one in a forward-facing child seat. (Singh et al, 2007)
15
Forward-facing Child Restraints with a Shield System
Child restraints with ‘shields’ or impact pads rather than an integral harness are
becoming more popular. It is estimated that about 10% of forward-facing child
restraints sold are shield systems, although, they are seldom observed in research
studies. An analysis of the performance of shield and harness systems in dummy
tests, found that the claims that shield systems protect the neck better than 5-point
harness systems, are not supported by the test results. To the contrary, the limited
accident data available suggested different neck injury patterns for shield systems
that cannot be evaluated with the current crash test dummies, and possibly higher
risks for the abdomen and thorax than with 5-point harness.
The report concluded that, based on the data that was analysed, the consequences
of the current revival of shield systems on child protection cannot be determined with
certainty. No clear benefit could be established from using shield-type restraints, and
it is unclear if test procedures are sufficient to evaluate shield systems’ real world
protection. (Johannsen et al, 2013)
Booster Seats and Booster Cushions
Booster seats are designed for children from about four years old until they are large
or old enough to use the vehicle’s seat belts. They aim to raise the child so that the
adult seat belt fits correctly. Those that have side impact wings also provide some
protection from side impacts.
The Swedish study of car accidents involving 3,670 children, aged 0-15 years,
between 1987 and 2004 found that children aged 4 to 10 years who used a booster
seat, which raises their body position so that the adult seat belt (which goes around
both the booster seat and the child sitting in it) fits them properly, were 77% less
likely to be injured in an accident, compared with an unrestrained child. The
researchers found that abdominal injuries mainly occurred in children using only a
seat belt, emphasising the need for belt-positioning boosters. (Jakobssen, 2005)
A study of 3,616 crashes involving 4,243 children aged 4 to 7 years in 15 States
between December 1998 and May 2002 found that 1.95% of those in seat belts were
injured, compared with only 0.77% of those in booster seats. The odds of injury,
adjusting for child, driver, crash, and vehicle characteristics, were 59% lower for 4 to
7 year old children in booster seats than in seat belts. (Durbin, 2000)
In children aged 4 to 7 years, booster seats were estimated to reduce the odds of
sustaining clinically significant injuries during a crash by 59% when compared with
using the vehicle’s seatbelts. (Ehiri, 2009)
Analysis of 10 years of data in the United States showed that 4 to 8 year old children
who were in booster seats were 7.7 times less likely to suffer moderate to serious
injuries in frontal impacts and 7.7 times less likely to suffer these injuries in side
impacts than unrestrained children, They were also 13.3 times less likely to suffer
moderate to serious injuries in rear impacts and 23.6 times less likely to suffer these
injuries in rollover crashes. (Singh et al, 2007)
16
There is evidence that the design of some booster seats needs to be improved to
reduce the risk of a child ‘submarining’ under the lap belt. Inspections and tests in
the USA found that most booster seats incorporate anti-submarining seat ramps,
seat surfaces and lap belt guide hooks, which help to minimize the potential for
submarining. However, two of the booster seats evaluated did not provide any
significant anti-submarining design. The authors called for features such as antisubmarining seat bottom ramps, low compressibility seating surfaces, and effective
lap belt guide hooks to be part of the requirements for booster seats.
(Whitman et al, 2013)
An analysis of the injuries suffered by 6 – 12 year old children in moderate to severe
collisions found that none of those in booster seats suffered moderate or severe
injuries, unlike those who were unrestrained, using an adult seat belt or using a
booster cushion. None of the children in side impact collisions who were using
booster seats or booster cushions suffered moderate or severe injuries. Chest
injuries were less common for children using booster seats than for those using
booster cushions or just the adult seat belt, possibly because booster seats help to
position the seat belt correctly and securely. However, the authors noted that the
numbers involved in the study were too small to draw conclusions. (Visvikis et al,
2009)
Although booster seats and booster cushions provide good protection for children
who are using them correctly, younger children face a higher risk of neck injuries in
these types of child restraints than in a forward-facing seat with an integral harness.
head injuries are the most common type of injury for children in these types of
restraints, with chest injuries being more common in booster cushions than in
booster seats (Lesire et al, 2010)
Risk According to Seating Position in the Car
A USA study of 17,980 children under 16 years of age involved in crashes between
1998 and 2002 concluded that while using appropriate child restraint provides more
protection than just sitting in the rear, the optimum protection is achieved by using an
appropriate child restraint in the rear of the vehicle rather than in the front. (Durbin,
2005)
An analysis of fatal car crashes in the USA between 1982 and 1987 showed that
unrestrained children were more likely to sit in the front, than in the rear seats, and
indicated that children sitting in the rear were 33% less likely to be killed than
children sitting in the front. (NHTSA, 1988)
17
Based on insurance claim records and a telephone survey of parents involved in
crashes with child occupants aged 0 to 3 years who were using a child restraint in
the rear of a vehicle it was estimated that children sitting in the centre had a 43%
lower injury risk than those seated in either of the rear outboard positions. (Kallan,
2008)
A study examining injury patterns among restrained 4 to 9 year olds by seat location
and the point of impact on their vehicle identified that the most serious injuries
occurred to children seated on the side of the vehicle that was impacted in lateral
collisions. (Agran, 1989)
A 1993 study identified that nearside impacts create a higher risk of injury to child car
occupants (Langweider et al, 1993, reported in Lesire et al, 2010). A 2004 study identified
that children sitting on the side of the vehicle that was struck are at much higher risk
of injury than children sitting on the opposite side of the vehicle (Arbogast et al, 2004,
reported in Lesire et al, 2010). Another 2004 study concluded that children sitting on
the nearside seat of the vehicle suffered more severe injuries than those sitting in the
centre or off-side seats. (Howard et al, 2004, reported in Lesire et al, 2010).
In the State of Victoria, Australia, data from almost 31,000 crash records found that
the relative risk of death for children under 4 years old in the front seat was twice as
great as when travelling in the rear, and the risk of serious injury was 60% greater.
The relative risk of death whilst travelling in the front seat was almost four times
greater for children aged under 1 year old. The authors suggested changing the law
to require children, especially under 5 year olds, to sit in the rear. (Lennon, 2008)
Analysis of fatal crashes in the United States between 2000 and 2003 showed that
sitting in the rear middle seat is safer than any other position. Overall, the rear seats
had a 29% increased odds of survival over the front seats and the rear middle seat
had a 25% increased odds of survival over the other rear seat positions. After
correcting for potential confounding factors, occupants of the rear middle seat had a
13% increased chance of survival when involved in a fatal crash than occupants in
other rear seats. (Mayrose and Priya, 2008)
However, an analysis of properly restrained child passengers from data in another
database, the National Automotive Sampling System (NASS), did not find that the
centre rear seat to be any safer than either of the outboard rear seats. (Lund 2005)
Although not specifically about child car passengers, a recent Australian study found
that rear seat car passengers are sustaining more severe injuries than front seat
passengers, possibly because of the introduction of safety features aimed at front
seat protection, such as frontal airbags. (Mitchell et al, 2015)
Child Restraints and Side Impacts
Side impacts account for about 25% of accidents involving children in cars. As noted
earlier, forward-facing child restraints are much more effective in frontal collisions
than in side impacts. In this research, although the number of side impacts in the
database was small, head injuries accounted for 62% of all severe injuries in all
types of restraint, indicating that the level of head protection is insufficient. (EEVC WG
18)
18
Severe chest and abdomen injuries also occurred, mainly in children using a booster
seat or booster cushion, or just using the adult seat belt. These injuries were rarely
seen in children using a restraint with a shell, such as rearward- and forward-facing
seats. Of the children involved in side impact collisions, 20% suffered severe injuries
and 43% minor injuries. (EEVC WG 18)
The analysis of almost 4,000 injured child car passengers in Swedish accident
records also identified that head injuries are the most frequent moderate or severe
injuries for side (as well as frontal) impacts. Although rearward-facing child seats are
designed primarily for frontal impacts, the Swedish data showed that they provided
good protection in side and rear-end impacts. In fact, the database contained no
rearward-facing child who had severe injuries in side or rear impacts. (Jakobsson et
al, 2005)
A TRL project that included research to develop a side impact test for child
restraints, identified from its fatal accident database that over one third (35%) of
children who were killed in car accidents even though they were using a child
restraint, were killed in side impacts (including sideswipes). It concluded that a
backrest with side wings could help to minimise head injuries in side impacts.
(Lowne, 2000)
A new standard for child car restraints, Regulation 129 (commonly referred to as isize) was introduced in July 2013. One of the main improvements this provided over
Regulation R44 is that it requires child car seats to provide better protection from
side impacts. UK law to allow Regulation 129 child car seats to be used came into
force in Spring 2015, therefore parents may now choose to child car seats that
conform to either Regulation 44 or to Regulation 129. (United Nations, 2013)
USE OF CHILD CAR RESTRAINTS
The table below shows the use of child restraints in Great Britain in 2008, two years
after the law was changed to require virtually all children to use child restraints until
they are either 135cm tall or 12 years old. It shows that three-quarters (74%) of 1 to
4 year old children travelling in the front of cars were using a child car restraint
(either a forward-facing child restraint or a booster seat or booster cushion), but most
(93%) did so in the rear. Older children (or 5 – 9 years) were much less likely to use
child car restraints, with only 28% doing so in the front and 43% in the rear. (TRL,
2008)
19
Use of restraints by younger children (%), October 2008
Front seat passengers Rear seat
passengers
1–4 years 5–9
1–4
5–9 years
old
years old years old old
Seat belt worn
20
71
5
51
Child seat used
53
0
75
6
Rear facing child seat used
0
0
1
0
Booster seats and cushions used:
Properly
21
28
18
37
Wrongly
0
0
0
0
Unrestrained:
on seats
5
1
1
6
on passenger’s lap
1
0
1
0
Misuse of Child Car Restraints
Although child car restraints are very effective at protecting children in cars, their
effectiveness can be reduced, or even negated altogether, if the restraint is
unsuitable for the child and/or is not correctly fitted in the car. Surveys over many
years have consistently found high levels of child car seat misuse and common
types of misuse.
An analysis of injury rates for car passengers under 15 years old in the USA in 1990
and 1991 found that 19% of children under 1 year old who were in an appropriate
restraint were injured, compared with 30% of those in an inappropriate restraint.
Children who were inappropriately restrained were at greater risk than those who
were appropriately restrained. (Johnston, 1994)
An observational survey in 2006 and 2007 found a high frequency of seat belt
misuse among children travelling in booster seats. Of 564 children in belt-positioning
booster seats, about two-thirds (65%) were misusing the seat belt in at least one
way. Common misuses were the shoulder belt being placed over the booster seat
armrest (35.8%), shoulder belt not at mid-shoulder position (28.5%), seat belt too
loose (24.5%), and the shoulder belt either behind the child's back (9.1%) or under
their arm (10.0%). (O’Neil et al, 2009)
Six case studies illustrating the injury patterns associated with various types of
restraint misuse in infants (under 1 year old), toddlers (aged 1 to 4 years), young
children (aged 4 to 8 years), and pre-teens (aged 8 to14 years), showed that
restraint misuse leads to increased morbidity and mortality for children in motor
vehicle crashes. (Bulger and Kaufman, 2008)
The use of child restraints by 635 child passengers aged 12 years or younger who
were treated in hospital for injuries sustained in vehicle crashes was analysed. Over
three- quarters (77%) of inappropriate restraint use was among children aged 4 to 8
years who were placed in seat belts before they were large enough for the seat belt
to fit properly. (Lee, 2008)
20
Some parents purchase second hand child car restraints, which may not provide the
best protection for their child. Hampshire County Council Trading Standards Service
conducted a study on the crash performance of second hand child restraints – all 15
child seats tested, failed to meet the (then current) R44.03 standard. (Willis, 2006)
Trials of parents attempting to fit child restraints into cars by following the
manufacturer’s instruction booklets illustrated that there was considerable variation
in the quality and user-friendliness of the instruction booklets, and that generally the
trial participants found them daunting and unhelpful. (RoSPA, 2001)
To help parents, many ‘Inspection Clinics’ (under various names) are run across
Britain to which parents are able to bring their child restraint, ideally in their car and
with the child who uses it, to a convenient location (such as a supermarket car park)
where the restraint is checked by an expert to assess whether it is suitable for the
child, for the vehicle and whether it is fitted correctly.
The CHild Injury Led Design (CHILD) project, part funded by the EC, included
literature reviews of the incorrect use of child restraints in several countries. In the
UK, surveys by local councils, child product manufacturers and safety organisations
consistently find high levels of child car restraint use, but low levels of correct fitting.
The project also identified a lack of confidence amongst parents about their ability to
fit their child restraints correctly. (Willis, 2006)
This project also found that children in inappropriate or incorrectly fitted child car
restraints are more likely to suffer severe injuries, especially more head injuries, in
accidents than children who are correctly restrained. However, they are still at lower
risk than children who are travelling unrestrained. (Willis, 2006)
Data from the EC-funded CASPER project found that misuse of child seats was still
a widespread and serious problem (based on studies in Berlin, Lyon and Naples).
The main problems were not threading the vehicle seat belt correctly through the
child restraint, and the general installation of the child seat in the vehicle
Comparisons between studies conducted in Lyon in 2003 and in 2011 showed the
average rate of misuse was about 71% in 2003 and 65% in 2011. The main
differences were with forward facing systems with an integral harness, the use of
which was better in 2011 than in 2003 with a decrease of serious misuse, such as
incorrect harness use. For booster seats, the most frequent misuse was the same in
2011 as in 2003, with the lower belt guides often not used and the chest part of the
seatbelt under the arm.
One of the other main faults, moving a child into the next type of child restraint too
early, had similar rates in 2003 and 2011.
Factors, such as the available time and the trip purpose, influenced how well parents
secured their children; they want to secure their child correctly, but it needs to be
easier and simpler for them to do so. Most of the misuse problems could probably be
reduced by providing better help and guidance top parents. (Lesire et al, 2013a)
21
An additional study in Belgium of 1,500 children illustrated the same tendencies as in
the other studies: many children not correctly restrained, child restraint use being
much lower for children older than 6 years, and too many parents not being aware
that they are not using child restraints properly. (Lesire et al, 2013a)
A roadside survey conducted in September 2011 by the Belgian Road Safety
Institute (BRSI) found that at least 50% of children were not correctly restrained and
10% were not restrained at all. The most significant factors associated with child car
restraint misuse were the use of a seatbelt by the driver, whether the restraint was
bought in a supermarket rather than a specialised shop and the age of the child.
Most of the drivers were ignorant of their errors in using their child car restraint
correctly or underestimated the risk. The three main reasons given by the drivers to
explain the misuse were low attention level to safety (inattention, time pressure, and
short distance), the child’s resistance to being restrained, children restraining
themselves and problems with the restraint.
The results suggested little or no change in the level of correct child car restraint use
over the last previous years. (Roynarda et al, 2014)
TRL developed a standardised form to record details of the type of restraint, the child
using it, and the way in which it is fitted. Initial analysis illustrated that 43% of parents
did not know the weight or height of their child, information that is crucial when
choosing a child car restraint. Although the appropriateness of the child restraints
being used was generally good, there was a trend to use forward-facing child
restraints as soon as possible, and sometimes too soon, with some being used by
children under 9 months old.
A trend to transfer children to booster seats as soon as possible was also seen, with
a large percentage of 3 year-olds using them. Most child restraints were compatible
with the vehicle in which they were used, but only 53% were correctly installed,
usually because the seat belt was too slack or incorrectly routed. (Pitcher, 2011)
A more recent analysis of records from child car seat checking clinics found that
levels of misuse of child car seats remain high and so education and checking clinics
are essential. Although most parents/guardians were able to provide the child’s age,
few knew their weight or height correctly, both of which are important when choosing
a child car seat that is appropriate for their child. 60% of the child car seats checked
had at least one form of misuse. (M Pitcher, 2015)
It has been suggested that the risk of misusing a shield-system restraint is lower
because it is not necessary to fit the child in the integral harness. However, the
number of cases is too small to draw any conclusion, except that shield systems are
seldom observed in the three CASPER study regions and Belgium. There was only
one shield system restraint in the CASPER sample, which was correctly used, and
only one in the Belgium sample, which was mis-used (used without the shield).
(Johannsen et al, 2013)
22
ISOFIX
is a system for the connection of child restraint systems to vehicles which has two
vehicle rigid anchorages, two corresponding rigid attachments on the child restraint
system and a means to limit the pitch rotation of the child restraint system.
It was developed to provide more a secure attachment to the vehicle and to make
fitting child car restraints easier. Basically, fitting points are built into both cars and
child car restraints when they are manufactured. An ISOFIX child restraint is simply
‘plugged’ into the corresponding fitting points in the car, removing the need to use
the car’s seat belts to secure the restraint. An additional top tether or bottom foot is
used to prevent the restraint from titling or rotating in a frontal impact.
The TRL project that contributed to the development of ISOFIX concluded that
ISOFIX with two rear rigid attachments together with an anti-rotation system, such as
a top tether, would provide a good basis for a universal system with greatly reduced
misuse rates and an improved dynamic performance in accidents. (Lowne, 2000)
In 2009, an AA/Populus Panel Survey of 7,791 driver sin 2008 estimated that at least
6 million cars in Great Britain (around 25% of all cars) were fitted with standardised
ISOFIX fittings, but 74% of drivers were unaware of ISOFIX. (AA, 2009)
As yet, there are few published studies assessing the effectiveness of ISOFIX seats
in real life. However, the EC-funded CASPER project included a study in Belgium
that included enough ISOFIX seats to enable comparisons to be made with
“classical” child restraints that are fitted with the vehicle seat belt. The rate of misuse
with ISOFIX was 2.3 times lower than with the “classical” ones. It was almost 3 times
lower for forward-facing ISOFIX restraints than for forward-facing child seats that are
fitted with the vehicle seatbelt. The difference between booster seats with ISOFIX
anchorages and standard booster systems was smaller, but still apparent.
However, the CASPER study also found that less than 4% of the restraints were
ISOFIX restraints, despite the fact that in 2011 around half vehicles were equipped
with ISOFIX anchorages. (Lesire et al, 2013a)
The EC-funded CASPER project found that the main problems are not threading the
vehicle seat belt correctly through the child restraint, and the general installation of
the child seat in the vehicle. Both these problems could be prevented by the use of
ISOFIX, but less than 4% of the restraints were ISOFIX restraints, despite the fact
that around 50% of the vehicle fleet was equipped with ISOFIX anchorages in 2011.
(Lesire et al, 2013a)
A study in Belgium of 1,500 children was able to compare ISOFIX systems with
“classical attachment” restraints. The rate of misuse with ISOFIX was 2.3 times lower
than with the “classical” ones. It was almost 3 times lower for forward-facing ISOFIX
restraints than for forward-facing child seats that are fitted with the vehicle seatbelt.
The difference between booster seats with ISOFIX anchorages and standard booster
systems was smaller, but still apparent. (Lesire et al, 2013a)
23
The 2011 roadside survey by the Belgian Road Safety Institute (BRSI) that found
that at least 50% of children were not correctly restrained suggested that the ISOFIX
system reduced misuse significantly, although only a small number of ISOFIX seats
were observed. (Roynarda et al, 2014)
An observational study in 2005 in the USA found that although the proportion of
LATCH-equipped child restraints (LATCH is a USA system similar to ISOFIX) being
correctly fitted in LATCH equipped cars had increased, correct fitting was still not
universal. The study did not compare LATCH-equipped child restraints with nonLATCH-equipped ones. (Decina, 2006)
A more recent USA survey of drivers’ use of top tether points when fitting forwardfacing LATCH child restraints found that only 56% of forward-facing child restraints
were installed with the top tether, and only 39% were installed with the tether
correctly. Drivers who installed child restraints without tethers most often said they
did not know about the tether or how to use it. (Eichelberger et al, 2014)
i-Size (Regulation 129 Child Car Restraints
R129 was developed to introduce regulations to enable the approval of enhanced
Child restraints to mitigate some of the problems associated with child restraint
systems (i.e., the levels of misuse, poorer protection from side impacts, children
being put in the next size restraint too soon). The proposals for a new regulation for
child restraint systems were developed by an informal UNECE working group. Their
recommendations were based on the work of the EC-funded EPOCh and CASPER
projects, working groups such as EEVC WG12 and WG18 and research projects.
(Lesire et al, 2013b)
The regulation introduces Child Restraints designated as i-Size. The i-size system is
a new UNECE regulation for child restraints, which was introduced on 9 July 2013
and will run in parallel with the existing R44.04 standard for the next few years.
"i-Size" (Integral Universal ISOFIX Child Restraint Systems) is a category of Child
Restraint System for use in all i-Size seating position designated as such in a motor
Vehicle. The system is intended to be plug and play in order to simplify the current
situation. I-Size seats must be marked with the I Size logo.
The current level of UNECE R129 covers child restraints which are designated as iSize Integral child restraints. i-Size integral child seats are intended for use in the
designated I-Size seating position points in the car, with the child restrained by belts
that are part of the child restraint. i-Size seats will fit appropriate designated I Size
positions in a vehicle i. Cars will need to provide designated i-Size seating positions
to achieve the maximum 5 star Euro NCAP rating.
The main changes that i-Size introduces are:
 Child restraint systems based on the child’s height rather than weight
 i-Size rearward-facing restraints will be for babies up to 15 months old
 a side impact test.
(UNECE, 2013)
24
Promoting Child Car Restraint Use
In 2006, a Department for Transport campaign to raise awareness of new laws about
using child restraints increased awareness about the need to use child restraints and
the details of the new laws. In a post-campaign survey almost two-thirds (63%) of
parents said they used a child restraint when transporting a child, up from 50%
before the campaign. Awareness of when children could move up to seat belts had
increased, as had awareness of the new laws from 45% in July to 93%. (DfT 2006)
Amongst those aware of the legislation, a quarter said they had changed the way
they transported children, most commonly by starting to put their children in child
restraints. However, a significant minority, especially those transporting older
children or transporting children less regularly, were still not doing so. (DfT 2006)
A review of studies published between 2000 and 2007 of the effectiveness of
education and legislation interventions to increase the use of child restraints found
sufficient evidence to suggest that such interventions are effective. The review found
five studies involving a total of 3,070 participants. All of the interventions investigated
increased the use of booster seats by the people who took part in the intervention,
compared to groups that did not. Distributing free booster seats combined with
education on their use, had a marked beneficial effect, as did financial incentives
(such as discount coupons or gift certificates) combined with education. Educationonly interventions also produced beneficial outcomes. (Ehiri, 2009)
Only one study evaluated the effectiveness of the enforcement of a booster seat law,
but did not detect an effect on usage. However, the authors also concluded that
there is a need for further high quality trials, especially outside the USA and
Australia, where current research dominates. (Ehiri, 2009)
An evaluation of a practical education intervention in the use of child car restraints
included 111 parents who were at least seven months pregnant and who were
randomly assigned to one of two groups (56 intervention and 55 control). All received
a free car seat and a standard education session on the use of child passenger
restraints, but the intervention group also received a hands-on demonstration of how
to correctly install and use the restraint in their own vehicle. Follow-up observations
after birth found that only 24 (22%) of the parents correctly used the child restraint, of
whom 18 (32%) were in the intervention group and 6 (11%) were in the control
group. The intervention group was four times more likely than the control group to
install and use the restraint correctly. (Tessier, 2010)
Child car restraint laws are one of the five key road safety laws named in the Global
Decade of Action for Road Safety, only 32% of the world’s population are covered by
such laws. They are more common in high income countries but new laws are being
enacted in middle and low income countries.
25
Even though child restraint laws are important, experience in high income countries
shows that high levels of compliance are difficult to achieve with education and
enforcement programmes, and support programmes to distribute child restraints.
According to the WHO, only 17% of the 96 countries with child restraint laws have
good enforcement programmes. (Keay et al, 2015)
A study of the effectiveness of four different child passenger safety leaflets on
parents’ knowledge, attitudes, and behavioural intentions related to best practice and
proper use of child restraints found that all the education leaflets improved parents’
messages knowledge, attitudes, and behavioural intentions, but the leaflet which
explained the risk-reduction rationale behind the information given performed best,
(K E Will et al, 2015)
An evaluation of a child car seat safety class held at a pediatric trauma center, and
attended by almost 500 parents, found that it was effective at increasing parental
knowledge about child passenger safety. Interactive and hands-on teaching methods
may have resulted in greater retention and comprehension of the messages than
more passive methods, such as showing a video in a hospital waiting room. (Muller
et al, 2014)
An evaluation of a multimedia DVD designed to improve knowledge about car seat
installation among parents of infants and toddlers found that it improved parents
knowledge and ability (on a simulated test) to use child car seat correctly. DVD
programs such as this offer a promising format for teaching, demonstrating, and
facilitating desired behaviour change by using visual examples and context, and
accommodate parents’ busy schedules, time constraints, and family obligations.
However, a significant challenge to public health advocates is dissemination of
effective programs to the target populations. (Swartz et al, 2013)
Disadvantaged Groups
A review of thirty-nine studies of interventions to increase the use of child restraints,
(including restraint loan schemes, educational campaigns, legislation and
enforcement) found that few targeted social and economic factors. However, there
was evidence that free or loaned child seat schemes increased the use of child car
restraints, and some evidence suggesting that although restraint use is higher
among higher socio-economic groups, lower social groups can be effectively
targeted. (Towner, 2004)
A review of road safety services for disadvantaged communities cited a scheme
providing a subsidy for buying child car seats as an example of good practice in that
it sought to understand and address a specific need in disadvantaged communities.
Providing child seats for taxis from maternity wards and child seat inspections were
other examples of interventions demonstrating recognition of the needs of this target
group and focusing on relevant issues for promoting behavioural change (i.e.
installing good child car seats). (Lowe, 2011)
26
In 2005 and 2006, a small number of local councils conducted road safety
interventions to supply and fit free baby seats for families from disadvantaged areas.
Families in deprived areas received a voucher which was redeemable at a local
retailer of child car restraints, whose staff showed the parents how fit the seat.
However, the schemes were expensive to run because of the cost of the seats, and
so their sustainability was questionable. (Hayes, 2008)
Between 2004 and 2006, after a local survey that found roughly 8 in 10 seats were
incorrectly fitted, free inspections of child car restraints were provided by trained fire
officers, alongside an educational campaign. Initially, the scheme was confined to
families in deprived areas, but they proved difficult to engage and uptake was poor
(despite anecdotal evidence suggesting that they drove the oldest cars and carried
most children, often without restraints), so the project was opened to all people in the
city who transported a child. (Hayes, 2008)
There is little evaluation to show whether such schemes are effective in reducing
casualties or improving child restraint fitment and use on a large scale, perhaps
reflecting the lack of well-structured evaluations rather than the schemes being
ineffective. (Hayes, 2008)
Room for Improvement
The ETSC Road Safety Performance Index (PIN), a policy tool to help EU Member
States improve road safety, assessed progress on improving car occupant safety in
the in the EU27 countries between 2001 and 2012. It found that deaths to car
occupants fell by 55% between those years, more than more than the fall of 49% in
the overall death rate. However, between 2010 and 2012 the car passenger fatality
rate for children (aged 0 to 14) per million child population varied between countries
from less than 1 to more than 8. (Jost et al, 2014)
Child car restraint laws are one of the five key road safety laws named in the Global
Decade of Action for Road Safety, only 32% of the world’s population are covered by
such laws. They are more common in high income countries but new laws are being
enacted in middle and low income countries.
Even though child restraint laws are important, experience in high income countries
shows that high levels of compliance are difficult to achieve with education and
enforcement programmes, and support programmes to distribute child restraints.
According to the WHO, only 17% of the 96 countries with child restraint laws have
good enforcement programmes. (Keay et al, 2015)
27
CHILD CAR RESTRAINTS: REFERENCES
Title:
Author:
Published:
Link:
Objectives:
Infants and Children in the Adult World of Automobile Safety
Design: Pediatric and Anatomical Considerations for Design of
Child Restraints
A R Burdi, D F Huelke, R G Snyder and G H Lowrey
Journal of Biomechanics, Vol. 2, pp. 267-28, 1969
http://deepblue.lib.umich.edu/bitstream/2027.42/32937/1/0000320.pdf
To identify general principles for child restraint systems based on the
basic anatomical differences between the adult and child.
To produce a profile of the anatomy, anthropomctry, growth, and
development of the infant and child to highlight age differences related
to the design of child restraint systems.
Literature Review
Methodology:
Key Findings:
 Infants and children are not miniature adults. Their anatomy differs from adults in a
number of ways. The design of occupant restraint systems needs to be based on
child anatomy not the anatomy of the adult.
 The frequency of head injuries in children in automobile accidents may be due to the
child's proportionately large head and higher center of gravity.
 Observations that the child's head is relatively massive and supported poorly from
below have been implicated in head snapping with rapid body deceleration, which
can traumatize related nerves, blood vessels, and spinal cord segments.
 The relative lack of skull protection, due to the fact that infants’ skulls are not an intact
bony case but a series of broadly spaced elastic bones, contributes to brain injuries in
young children.
 Differences in size, structure, shape, and biomechanical properties of the infant, child,
and adult pelvic skeleton must be considered in terms of lap belt design, position, and
vehicle anchorage. Key differences include insufficient space in the pelvic-thigh angle
for adequate positioning of the adult lap belt on the child.
 Unlike the adult, the organs of the chest are housed in an elastic and highly
compressible thoracic cage, and are extremely vulnerable to non-penetrating impacts
to the chest. The thoracic cage is not amenable to direct trauma or loading of webbed
restraints in children.
 The most effective restraint systems for children are those which distribute impact
forces over a large portion of the body.
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Seat Belts and Child Restraints: A Road Safety Manual for
Decision-makers, and Practitioners
World Health Organisation
World Health Organisation, 2009
http://whqlibdoc.who.int/road_safety/2009/9780956140302_eng.pdf
To provide advice and examples that will lead to increased use of seat
belts and child restraints as safety devices at a national level.
Literature Review, Case Studies and Good Practice Guide.
Methodology:
Key Findings:
 Seat belts save lives and significantly reduce injury severity for vehicle occupants.
 Around half of deaths of front seat occupants could be prevented by seat belts.
 Motor vehicle users make up a high proportion of traffic injuries and deaths in highincome countries, and the proportion is increasing in low- and middle-income
countries. It is vital that seatbelt use is increased in these countries.
 Children should use restraints that are suitable for their height and weight. This
reduces deaths of children by between 50% and 75%.
 Mandatory seat-belt legislation, combined with public education campaigns, is
effective at increasing seat belt wearing rates and thus reducing injuries and fatalities.
 Continuous and fair enforcement of the law is essential for raising rates to a
significant level. This requires strong commitment from both governments and
enforcement agencies.
 A well-designed marketing and publicity campaign is essential.
 Educational programmes, combined with other activities, can help shift behavioural
norms towards making seat-belt use more acceptable.
 Evaluation should be an integral component of any programme.
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Child Passenger Safety
American Academy of Pediatrics
Pediatrics 2011; 127;788, March 2011
http://pediatrics.aapublications.org/content/127/4/788.full.html
To provide evidence-based recommendations for best practice in the
choice of a child restraint system to optimize safety in passenger
vehicles for children from birth to adolescence.
Literature Review
Methodology:
Key Findings:
 Child passenger safety has dramatically evolved over the past decade, but motor
vehicle crashes remain a leading cause of death of children 4 years and older.
 Best practice recommendations for a child restraint systems to optimize safety in
passenger vehicles for children from birth through adolescence are:
 rearfacing car safety seats for most infants up to 2 years of age.
 forward-facing car safety seats for most children through 4 years of age.
 belt-positioning booster seats for most children through 8 years of age.
 lap-and-shoulder seat belts for all who have outgrown booster seats.
 all children younger than 13 years to ride in the rear seats of vehicles.
 Every transition from one type of child restraint to another is associated with some
decrease in protection; therefore, parents should be encouraged to delay these
transitions for as long as possible.
 The American Academy of Pediatrics urges all paediatricians to know and promote
these recommendations as part of child passenger safety anticipatory guidance at
every health-supervision visit.
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Rearward Facing Group 1 CCS
Advise use of rear facing child car seats for children under 4 years
old
Elizabeth A Watson, and Michael J Monteiro
British Medical Journal (BMJ), 11 June 2009
http://www.bmj.com/content/338/bmj.b1994.extract
To explain why it is safer for young children to travel in a rear facing
seat until they are 4 years old.
Literature Review
Methodology:
Key Findings:
 Many babies are switched from a rear facing car seat to a forward facing seat at 9 kg
(8 months of age for a boy on the 50th centile)
 The relatively large head mass and differences in the anatomy of the cervical spine in
young children can lead to excessive stretching or even transection of the spinal cord
if a child is involved in a frontal (head-on) crash while in a forward facing car seat.
 Rear facing seats are safer than forward facing seats for children under 4 years old
 Parents and guardians should be advised to keep young children in rear facing seats
for as long as possible
 In many countries it is a legal requirement that children under a certain height or age
(1 m 35 cm or 12 years, in the United Kingdom) to use child restraints appropriate for
their weight while travelling in a car. This significantly reduces morbidity and mortality.
 Many babies are switched from a rear facing to forward facing seat at 9 kg (age 8
months for a boy on the 50th centile. However, evidence is mounting, however, that it
is safer for young children to travel in a rear facing seat until 4 years of age.
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Methodology:
Safety For The Growing Child – Experiences From Swedish
Accident Data
Lotta Jakobsson, Irene Isaksson-Hellman, Björn Lundell
International Technical Conference on the Enhanced Safety of Vehicles
(ESV), 23rd Conference, Paper Number 05-0330, 2005
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv19/05-0330-O.pdf
To evaluate child safety with respect to age, size in different impact
situations and to identify optimal restraints and potential areas for
improvement.
Analysis of car crashes from Volvo's statistical accident database
between 1987 and 2004 involving 3,670 children, aged 0-15 years.
Key Findings:
 During the past 40 years, different child restraint systems have been developed to
improve protection for children of different sizes and ages.
 The development of more effective child restraints, and increased use of restraints, in
addition to enhanced vehicle safety, has increased child safety.
 The injury-reducing effect of the child restraint systems was high overall.
 The highest injury-reducing effect was found in rearward facing child restraints for
children up to 3-4 years of age, offering an injury-reducing effect of 90% compared to
an unrestrained child.
 Belt positioning boosters from 4 to 10 years of age were found to have an injury
reducing effect of 77%.
 Compared to adults, children have a generally lower AIS 2+ injury rate, except for
abdominal and lower-extremity injuries.
 Abdominal injuries are mainly found in children using only a seat belt, emphasising
the need for belt-positioning boosters.
 A tendency of higher injury risk was found when the growing child switches from one
restraint to another, i.e. when the child is at the youngest age approved for the
restraint.
 Thus, the total injury-reducing effect would increase if all children were to use the
child restraint system most appropriate for their size and age.
 The challenge is to spread information as well as enhance design to encourage
everyone to use the appropriate child restraint system and to use it correctly.
 Head injuries are the most frequent moderate or severe for side (as well as frontal)
impacts.
 The head is by far the most injured body region in side impacts, while in frontal
impacts the injuries are more evenly distributed over the different body parts.
 Rearward-facing child seats are designed primarily for frontal impacts, however the
outcome for side and rear-end impacts indicates a good performance in these
situations.
 No rearward-facing child sustained MAIS 2+ injuries in side or rear-end impacts.
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Lives Saved Through Child Restraints 82 to 87
National Highway Traffic Safety Administration (NHTSA)
National Highway Traffic Safety Administration, 1988
http://www-nrd.nhtsa.dot.gov/Pubs/807371.pdf
To measure the level of child restraint use and their effectiveness in
reducing fatality risk compared with children using seat belts and
unrestrained children.
An analysis of fatal car accidents in the USA between 1982 and 1987
involving cars equipped in which the use of restraints or not by the
driver and child passengers was reported. Fatality odds ratios were
calculated using a matched pairs technique.
Key Findings:
Between 1982 and 1987
 Child safety seats reduced the risk of death among infants (under 1 year old) by 69%.
 Child safety seats reduced the risk of death among toddlers (1 – 4 year olds) by 47%.
 Using an adult seat belt reduced the risk of death by 36% for toddlers.
 Child safety seats saved an estimated 838 children’s lives, and if all children had
been using child safety seats over that period a further 2,349 children’s lives could
have been saved.
 Children in child safety seats were 50% less likely than unrestrained children to be
killed, whereas children using the car’s adult seat belts were only 36% less likely to
be killed.
 Unrestrained children were more likely to sit in the front, than in the rear, seats, but
children sitting in the rear were 33% less likely to be killed than children sitting in the
front.
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Revised Estimates of Child restraint Effectiveness
National Highway Traffic Safety Administration
National Highway Traffic Safety Administration, 1996
http://www-nrd.nhtsa.dot.gov/Pubs/96855.pdf
To update the results of the 1988 NHTSA report above.
An analysis of fatal car and light truck vans accidents in the USA
between 1988 and 1994 in which the use of restraints or not by the
driver and child passengers was reported. Fatality odds ratios were
calculated using a matched pairs technique.
Key Findings:
In Cars:
 Between 1988 and 1994 child safety seats reduced the risk of death among infants
(under 1 year old) by 71% (up from 69%).
 Between 1988 and 1994 child safety seats reduced the risk of death among toddlers
by 54% (up from 50%).
 Between 1988 and 1994 using an adult seat belt reduced the risk of death by 47% for
toddlers (up from 36%).
In light trucks and vans:
 Between 1988 and 1994 child safety seats reduced the risk of death among infants
(under 1 year old) by 58%.
 Between 1988 and 1994 child safety seats reduced the risk of death among toddlers
by 54% (up from 59%).
 Between 1988 and 1994 toddlers using adult seat belts reduced the risk of death by
47%.
Overall:
 Children are 26% less likely to be fatally injured if sitting the rear of a vehicle.
 The maximum potential for reducing the risk of death for child passengers is achieved
by children using an appropriate child restraint in the rear of the vehicle.
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Traffic Safety Facts: Children: 2011 Data
Author:
National Highway Traffic Safety Administration
Published:
National Highway Traffic Safety Administration, 2013
Link:
http://www-nrd.nhtsa.dot.gov/Pubs/811767.pdf
Objectives:
To analyse and present data about child road fatalities in the USA.
Methodology:
Analysis of child fatality data in the USA.
Key Findings:
 Motor vehicle crashes were the leading cause of death for children aged 4 years, and
aged between 11 and 14 years.
 1,140 children aged 14 years or younger were killed on USA roads in 2011, 4% of
total road deaths.
 Lap and shoulder seat belts reduce the risk of death for front seat car occupants aged
5 or older by 45%, and reduce the risk of moderate to critical injury by 50%.
 Research on child safety seats has found that they reduce the risk of fatal injuries by
71% for infants (under 1 year old) and by 54% for toddlers (1 – 4 years old) in cars.
 In 2011, 663 children under 5 years old were saved by restraints, 245 of whom were
using child safety seats, and 18 were using seat belts. A further 51 lives could have
been saved if child safety seat use was 100%.
 Between 1975 and 2001, an estimated 9,874 lives (children under 5 years old) were
saved by child safety seats.
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Methodology:
Child passenger restraint use and emergency department–
reported injuries: A special study using the National Electronic
Injury Surveillance System–All Injury Program, 2004
Karen C. Lee, Ruth A. Shults, Arlene I. Greenspan, Tadesse
Haileyesus & Ann M. Dellinger
Journal of Safety Research, Volume 39, Issue 1, pp 25–31, 2008
http://www.sciencedirect.com/science/article/pii/S0022437507001429
To assess levels of use, mis-use and non-use of child car restraints
among different groups.
Review of accident records for 635 injured children aged 12 years or
younger who were treated at 15 hospital EDs in 2004 and interviews
with parents of children attending an Emergency Department having
being injured in a road accident.
Key Findings:
 In 2004, more than 180,000 child passengers aged 12 years or younger sought care
in U.S. hospital emergency departments for injuries sustained in vehicle crashes
 9% of the children were unrestrained and 36% were inappropriately restrained.
 Black and Hispanic children were about six times more likely to be unrestrained than
Non–Hispanic Whites (12% and 14%, respectively, vs. 2%).
 77% of inappropriate restraint use occurred among children aged 4–8 years, who
were prematurely placed in seatbelts.
 8% of children required hospitalization; unrestrained children were three times more
likely to be hospitalized than restrained children (21% vs. 7%).
 Age–appropriate restraint use should be promoted for child passengers, particularly
among Blacks, Hispanics, and children riding in trucks.
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Car restraints and seating position for prevention of motor vehicle
injuries in Greece
E Petridou, A Skalkidou, I Lescohier, D Trichopoulos
Arch Dis Child; 78(4): 335–339, April 1998
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1717544/
To assess the protective effect of child restraints and the relative safety
of front and rear seating in a population where children often travel
unrestrained.
A population control study of children aged 0–11 years injured as car
passengers in a motor vehicle accident in 1996 and treated at one of
the two major children’s hospitals in Athens, and an observational study
of a random sample of 191 children of the same age travelling in cars.
Key Findings:
 The Odds Ratio for injury was 3.3 among unrestrained children compared with
restrained children (comparison essentially limited to children aged 0–4 years).
 The Odds Ratio for injury was 5.0 for children seated in the front compared with those
seated in the rear (comparison essentially limited among unrestrained children).
 In Greece about two thirds of all childhood injuries from car crashes could have been
avoided through the regular use of a proper child restraint.
 In the absence of a child restraint system, a rear seating position conveys substantial
protection and could explain the low mortality of children as car passengers in
Greece, a country which is characterised by a high overall road traffic mortality.
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Methodology:
Children in Car Crashes: Analysis of Data for Injury and Use of
Restraints
Carden Johnston, Frederick P. Rivara, Robert Soderberg
Pediatrics Vol. 93 No. 6 pp. 960 –965, June 1 1994
http://pediatrics.aappublications.org/content/93/6/960
To determine the effect of car restraints on motor vehicle injury
rates for children aged 0 to 14 years.
A probability sample of reported car crashes in the United States in
1990 and 1991 was analyzed for injury rates of passengers under
15 years in relation to restraint usage, age, and seating position.
Key Findings:
 Optimal restraint usage (defined as car seats for children 0 to 4 years old and lap
shoulder belts for children 5 to 14 years old) was 40%.
 The use of car seats was 76% for infants (0 to 12 months old) and 41% for toddlers (1
to 4 year olds). The non use of a restraint was highest for 10 to 14 year olds (43%).
 19% of under 1 year olds who were in an appropriate restraint were injured,
compared with 30% of those in an inappropriate restraint and 40% of those who were
not restrained.
 For 1 to 4 year olds, 17% of those appropriately restrained, 22% of those in a seat
belt and 43% of those unrestrained were injured.
 For 5 to 9 year olds, the relative proportions were 29%, 26% and 44% and for 10 to
14 year olds, they were 28%, 29% and 49%.
 Children of all ages faced a much greater chance of being injured if they were
unrestrained. Children who were inappropriately restrained were at greater risk than
those who were appropriately restrained.
 Unrestrained children were 1.5 to 2.5 times more likely to be injured than restrained
children.
 Use of the child car seat reduced injuries by 60% for 0 to 4 year olds, whereas the lap
shoulder harness was only 38% effective for 5 to 14 year olds. Injury rates of
unrestrained 0 to 4 and 5 to 14 year olds were similar.
 Greater involvement in car crashes and less use of car restraints explains the 64%
higher rate of injury for 3 year olds than for infants. It is time to target the toddlers.
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Effectiveness of Child Safety Seats vs Safety Belts for Children
Aged 2 to 3 Years
Eduard Zaloshnja, Ted R. Miller and Delia Hendrie
Archives of Pediatrics & Adolescent Medicine
Arch Pediatr Adolesc Med.161(1):65-68, 2007
http://archpedi.ama-assn.org/cgi/content/abstract/161/1/65
To compare the effectiveness of child safety seats and lap-shoulder
belts in rear passenger vehicle seats for 2 to 3 year-old crash survivors.
Cohort study of a nationally representative sample of crashes in the
USA involving toddlers who were sitting in the rear and using lapshoulder belts or child seats, between 1998 and 2004.
Key Findings:
 The adjusted odds of injury were 81.8% lower for toddlers in child seats than belted
toddlers.
 Child safety seats seem to be more effective rear seat restraints than lap-shoulder
safety belts for children aged 2 to 3 years.
 Laws requiring that children younger than 4 years travel in child safety seats have a
sound basis and should remain in force.
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Methodology:
Effectiveness of child safety seats vs seat belts in reducing risk
for death in children in passenger vehicle crashes
Elliott MR, Kallan MJ, Durbin DR, Winston FK
Archives of Pediatrics & Adolescent Medicine
Arch Pediatr Adolesc Med;160(6):617-21, June 2006
http://www.ncbi.nlm.nih.gov/pubmed/16754824
To provide an estimate of benefit, if any, of child restraint systems over
seat belts alone for children aged from 2 to 6 years.
Cohort study of a sample of children in US passenger vehicle crashes
involving a fatality and a probability sample of cases without a fatality
between 1998 and 2003.
Key Findings:
 Compared with seat belts, child restraints, when not seriously misused (eg,
unattached restraint, child restraint system harness not used, 2 children restrained
with 1 seat belt) were associated with a 28% reduction in risk of death in children
aged 2 to 6 years after adjusting for seating position, vehicle type, model year, driver
and passenger ages, and driver survival status.
 When including cases of serious misuse, the effectiveness estimate was slightly lower
(21%).
 Based on these findings as well as previous epidemiological and biomechanical
evidence for child restraint system effectiveness in reducing nonfatal injury risk,
efforts should continue to promote use of child restraint systems through improved
laws and with education and disbursement programs.
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Methodology:
The Effect Of Restraint Use And Crash Mode On Injury Severity
Risk For Children
Santokh Singh, Linda McCray and John Brewer
International Technical Conference on the Enhanced Safety of Vehicles
(ESV) 20th Conference, Paper Number 07-0216, 2007
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv20/07-0216-O.pdf
To study the effect of restraint use under different risk scenarios
consisting of some possible contributors to injury risk: the restraint use,
impact type, injury severity, and age of crash involved children.
Data analysis of children of age groups: infants, 1 to 3, 4 to 8, and 9 to
12 year olds, who were either uninjured, or sustained minor to fatal
injuries in frontal, side, rear-end, or rollover crashes from the National
Automotive Sampling System– Crashworthiness Data System (NASSCDS) 1994 to 2004.
Key Findings:
In general, the restrained children were found much safer against injuries.
1 – 3 year old Children
 The relative risks of 0.303, 0.349, and 0.76 for MAIS=0 in frontal, side and rollover
crashes show that there are low chances of protection against injuries for these
children when they are unrestrained.
 The relative risks of 0.88, 0.79, 0.51in frontal, side, and rear-end crashes are
indicative of low risk of minor injury to 1 to 3 year olds in these types of crashes.
 In rollover crashes, the relative risk of 10.33 of minor injury to an unrestrained child is
about 7 times higher than the relative risk 1.42 to a restrained child.
 For moderate to serious injuries, restrained children have low relative risks of serious
injury: 0.71, 0.92, and 0.88, respectively, for frontal, side, and rear-end crashes.
 The risk (10.44) to an unrestrained child in rollover crashes is about 10 times higher
than the relative risk (1.48) to a restrained child.
4 to 8 year olds Children
 In side, rear, and rollover crashes, these children have greater chance of being
uninjured when they are restrained.
 For minor injuries, the restrained children showed a low risk in side, rear and rollover
crashes, these children have a higher risk 1.6 of sustaining minor injury in frontal
crashes when they are unrestrained as compared with restrained children.
 The restrained children of this age group have much lower relative risks of moderate
to serious injuries: 0.47 in frontal, 0.80 in side, 0.15 in rear impacts, and 0.24 in
rollover crashes. In fact, the relative risks for the unrestrained group were,
respectively, 7.7, 7.6, 13.3, and 23.6 times higher than the restrained children.
9 to 12 year old Children
 The relative risks of no injury or minor in frontal, rear and rollover crashes for the
restrained group show that the restraint use provided protection against injuries to
these children in these crashes. Also, the relative risk of sustaining injuries in side
impacts was higher for the unrestrained children.
 The relative risks of serious to moderate injuries: 0.81 in frontal, 0.87 in side, 0.68 in
rear-end, and 0.79 in rollover crashes for the restrained group show that the restraint
was protective for 9 to 12 years old children against moderate to serious injuries in
these types of crashes.
 The results show the overall effectiveness of restraint use in protecting the children
from different crash impacts. The level of injury to a child may further depend on
whether the frontal impact was full, offset, or center and side impact was near-side or
far-side.
 Sample sizes in some sectors of the data were not large enough to statistically
validate the findings. The reason for limited or insufficient data could either be the
38
rare occurrence of certain risk factor combinations or the result of insufficient attention
in collecting the pertinent data.
 This shows the necessity of collecting more data in such sectors of the data so that
valid conclusions can be drawn about restraint systems effectiveness.
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An evaluation of the effectiveness of forward facing child restraint
systems
Kristy B. Arbogast, Dennis R. Durbin, Rebecca A. Cornejo, Michael J.
Kallan, Flaura K. Winston
Accident Analysis & Prevention, Vol 36, Issue 4, pp 585–589, July 2004
http://www.sciencedirect.com/science/article/pii/S0001457503000654
To determine the effectiveness of forward facing child restraint systems
in preventing serious injury and hospitalization to children 12–47
months of age as compared with similar age children in seat belts.
A cross-sectional study of children aged 12–47 months in crashes of
insured vehicles in 15 states, with data collected via insurance claims
records and a telephone survey. Completed survey information was
obtained on 1,207 children, representing 12,632 children in 11,619
crashes between 1 December 1998 and 31 May 2002.
Key Findings:
 Serious injuries occurred to 0.47% of all 12–47-month olds studied, including 1.72%
of those in seat belts and 0.39% of those in child restraint systems.
 The risk of serious injury was 78% lower for children in forward-facing child restraint
systems than in seat belts.
 The risk of hospitalization was 79% lower for children in forward-facing child restraint
systems than in seat belts.
 There was no difference between the restraint types in preventing minor injuries.
 As compared with seat belts, child restraint systems are very highly effective in
preventing serious injuries and hospitalization.
 This effectiveness estimate is substantially higher than older estimates,
demonstrating the benefits of current child restraint systems designs.
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Methodology:
A Prospective study of children as car passengers in road traffic
accidents with respect to restraint effectiveness
H. Gustafsson, Å. Nygren and C. Tingvall
Acta Pediatrica, Vol76, Issue s339, Oct 1987
http://onlinelibrary.wiley.com/doi/10.1111/j.16512227.1987.tb10581.x/abstract
To assess the types of injuries suffered by child car passengers and the
effectiveness of child car restraints in preventing such injuries.
Epidemiological study of injuries to children as car passengers in road
traffic accidents.
Key findings:
 Protective measures should be focused on the head region, as both fatal and
disabling injuries occur mainly in this part of the body.
 Unrestrained children at greatest risk; children in rear-facing child restraints at lowest
risk.
 The injury risk for children aged 0 – 4 years was almost 5 times greater in a forwardfacing child restraint than in a rearward-facing one.
 Rearward-facing seats were 90% effective and forward-facing seats in rear outboard
position were 60% effective at reducing injuries.
 Forward-facing seats distinctly more effective in frontal collisions than in side impacts.
All the seats were boosters, ie no internal harness.
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Title:
Cervical Spine Fractures Sustained by Young Children in ForwardFacing Car Seats
Author:
Fuchs S et al
Published:
American Academy of Pediatrics
Pediatrics Vol 84 No 2, pp 348-352, August 1989
Link:
http://pediatrics.aappublications.org/content/84/2/348.abstract?sid=289
e6f55-df7c-4e33-9ba6-d16edbc2d09b
Objectives:
To examine injury patterns to children involved in car crashes while
using (correctly or incorrectly) child safety seats.
Methodology: Data on children injured in a car accident between October 1985 and
March 1987 was collected from police and hospital records and from a
survey of parents. Where possible the car safety seat in use at the time
was examined.
Key Findings:
 Laws have increased the use of child safety seats and helped to reduce child deaths
and injuries in cars
 However, there has also been an increase in the misuse of such seats, with as many
as 74% being incorrectly used.
 In some cases this results in severe cervical spine injuries to children.
 Five cases of severely injured children are presented
o A 16 month old girl had been unsecured in a forward-facing child seat, which
was secured only by a lap belt
o A 12 month old boy had been unsecured in a forward-facing child seat, which
was not secured by a seat belt and was thrown onto the dashboard.
o A 23 month old girl was had been restrained in a forward-facing child seat,
which was secured but she was still injured
o A 9 month old boy in a forward-facing child seat was fatally injured (as was
the driver)
o A 9 month old boy in a forward-facing seat was secured by the car’s seat belt
not by the child seat’s harness
 Public and parent education in the proper use of child car restraints is necessary.
 A redesigned child safety seat that allowed children to travel rearward-facing until 2
or 4 years of age would help to reduce severe head and neck injuries to child
passengers.
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Rearward-Facing Child Seats – The Safest Car Restraint For
Children?
G Carlsson et al
Accident Analysis & Prevention, Vol. 23, Nos. 2/3, pp 175-182, 1991
http://www.ncbi.nlm.nih.gov/pubmed/2029318
To evaluate the effectiveness of child restraints in reducing the risk of
injury to child car passengers in Sweden.
Analysis of accident data from 1,500 accidents that occurred between
1976 and 1988 and in which at least one child (0 to 14 years) was
present in the vehicle. Attitudinal survey amongst drivers about child
safety in cars.
Key Findings:
 The use of child restraints in cars in Sweden has rapidly increased, with the major
emphasis being on using rearward-facing child seats for children 0 to 4 years of age.
 There are two types of rearward-facing child restraints used in Sweden: ‘infant seats’
for babies from 0 to about 6 months old that can be used in the front or rear of the car
and ‘toddler seats’ for children aged from about 6 months to about 4 years, which are
used mainly in the front of cars.
 Using rearward-facing restraints reduced the risk of injury by between 76% and 92%.
 Using forward-facing child seats reduced the risk of injury by between 34% and 60%.
 Unrestrained children had the highest injury risk.
 Of the rearward-facing child seats in these accidents, 6% were incorrectly fitted.
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Premature infants in car seats
Bull MJ and Stroup KB
American Academy of Pediatrics
Pediatrics 1985;75:336–9,1985
http://pediatrics.aappublications.org/content/75/2/336.abstract?sid=cd32b
0ef-5fa1-4d61-8325-5e64ae7276de
To assess the suitability of various types of infant car safety seats for
premature infants
Babies weighing 2.0-kg (4 lb 8 oz) were placed in a representative
sample of seat models. Ease and ability of the seat to fit the size of the
infant and allow for proper positioning of the baby was noted.
Key Findings:
 Advancements in health care have made it possible for many premature infants
weighing less than 2.2 kg (5 lb) to be discharged from the hospital.
 Medical professionals, however, have no information available from which to make
recommendations about which child safety seats are most appropriate for safely
transporting low-birth-weight infants.
 Current federal safety standards do not specify the minimum weight of an infant for
which a seat is appropriate.
 Convertible seats with seat back to crotch strap height of 14 cm (5½ in) or less
provided relatively good support for the infant.
 Seats with longer seat back to crotch strap distances allowed the infant to slouch.
 Seats with lap pads or shields were uniformly unacceptable.
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42
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Methodology:
Risk of hypoventilation in premature infants in car seats
M. P Leuschen, R.N. Linda S. Nelson & Robert M Nelson Jr
The Journal of Pediatrics, Volume 109, Issue 2, Pages 245-248, August
1986
http://www.ncbi.nlm.nih.gov/pubmed/3734961
To assess whether currently available car seats may place premature
infants at risk for significant hypoxia and ventilatory compromise.
 Examinations of 30 newborn infants for respiratory compromise
before, during, and after placement in a recommended child car
restraint. Twelve of the infants were premature with a history of
apnea, eight were premature without known apnea, and 10 were born
at term.
Key Findings:
 Both premature groups had significant decreases in oxygen saturation while in the car
seat and more frequent desaturation episodes.
 Premature infants with a history of apnea had more bradycardia events.
 No normal term infant had any of these problems.
 In addition, oxygen saturation trended downward from baseline for all premature infants
during the recovery interval.
 Currently available car seats may place premature infants at risk for significant hypoxia
and ventilatory compromise.
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Safe Transportation of Preterm and Low Birth Weight Infants at
Hospital Discharge
Marilyn J. Bull and William A. Engle
American Academy of Pediatrics
Pediatrics 2009; 123; 1424, 2009
http://pediatrics.aappublications.org/content/123/5/1424.full.pdf+html
Objectives:
To ensure that preterm and low birth weight infants are transported safely.
Methodology: Literature Review
Key Findings:
 Preterm infants are subject to an increased risk of oxygen desaturation, apnea, and/or
bradycardia, especially when placed in a semi-reclined position in car safety seats.
 Therefore, monitoring in the infant’s own car safety seat before discharge from the
hospital should be considered for all infants less than 37 weeks’ gestation at birth to
determine if physiologic maturity and stable cardio-respiratory function are present.
 The amount of time the infant is seated in a car safety seat should be minimized, and car
safety seats should be used only for travel.
 A conventional car safety seat that allows proper positioning of the preterm infant should
be selected if a semi-upright position can be maintained safely by the infant.
 However, an approved car bed may be indicated for infants who manifest apnea,
bradycardia, or low oxygen saturation when positioned semi-reclined in a car safety seat.
Such should travel in a supine or prone position in car bed after an observation period
that is free of such events as described above.
 If a car bed is considered, a period of cardio-respiratory monitoring while the infant is in
the car bed should be performed before discharge.
 Before transitioning from a car bed, a period of observation of an infant for apnea,
bradycardia, and oxygen desaturation in the infant’s own semi-reclined car safety seat
should be considered.
 Infants for whom home cardiac and apnea monitors are prescribed should use this
monitoring equipment during travel. The equipment should be wedged on the floor or
under the vehicle seat to minimize the risk of it becoming a dangerous projectile in the
event of a crash or sudden stop.
 Guidance for selecting car safety seats and positioning preterm and low birth weight
infants is provided.
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Pre-discharge "car seat challenge" for preventing morbidity and
mortality in preterm infants
Elizabeth Pilley and William McGuire
Cochrane Neonatal Group, 2009
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005386.pub2/pdf
To assess the available evidence that pre-discharge cardiorespiratory
monitoring in a car safety seat prevents morbidity and mortality in
preterm infants.
Literature review of randomised or quasi-randomised controlled trials that
compared pre-discharge cardiorespiratory monitoring in a car seat versus
no monitoring of preterm infants in the week prior to planned discharge
from hospital.
Key Findings:
 Physiological monitoring studies indicate that some preterm infants experience episodes
of oxygen desaturation, apnoea, or bradycardia when seated in standard car safety
seats.
 The American Academy of Pediatrics recommends that all preterm infants should be
assessed for cardiorespiratory stability in their car seat prior to discharge - the "car seat
challenge".
 We did not find any randomised controlled trials that that compared pre-discharge
cardiorespiratory monitoring in a car seat versus no monitoring in preterm infants in the
week prior to planned discharge from hospital
 It is unclear whether undertaking a pre-discharge car seat challenge is beneficial or
harmful to preterm infants.
 Further studies are needed to determine whether the car seat challenge accurately
predicts the risk of clinically significant adverse events in preterm infants travelling in car
seats.
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45
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Methodology:
Analysis of the Performance of Different Architectures of Forward
Facing CRS with Integral Restraint System
H Johannsen, P Beillas and P Lesire
International Technical Conference on the Enhanced Safety of Vehicles
(ESV) 23rd Conference, Paper Number 13-0226, 2013
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv23/23ESV-000226.pdf
To analyse the performance of shield and harness systems in dummy
tests, to analyse the limited accident data available and discuss the
possible impact on future child safety.
1) Accident data, using the CASPER project accident database
2) Test results, using new tests and a reanalysis from previous tests
provided by third parties
3) Results from misuse field studies.
Key Findings:
 According to ECE R44, children with a weight between 9 and 18 kg shall use a child
restraint with integral restraint system, which are normally forward facing. Two types
fulfilling the integral restraint system requirements can be found on the European
market: 5-point-harness systems and shield systems.
 While shield systems were very popular, they had disappeared by the end of the
1990s. Today they are subject of a revival. Although a considerable number of shield
systems are on sale, and it is estimated they have a market share of 10%, they are
seldom observed in field data (accident data, misuse studies, and biomechanical
studies).
 Shield systems are advertised to offer better neck protection in frontal impacts than 5point-belt harness systems. In recent European consumer information campaigns
they are often rated good. The only good rated group I/II/III CRS in 2012 were shield
systems. The number of child restraint manufacturers offering shield systems is
increasing.
 To restrain children in harness systems two independent actions are required, fixing
the restraint to the vehicle and securing the child in the restraint, while in shield
systems the restraint and occupant are secured by only one action. This means that
the general misuse risk is lower in shield systems.
 However, not using the impact shield is a potential severe misuse. The impact shield
may be perceived uncomfortable by children and may result in children resisting
using the impact shield.
 Harness systems and shield systems interact in very different manners with the child,
especially when skeletal load bearing structures are considered. Because is it
flexible, the harness adapts to the shape of the child and potentially transfers loads to
the most rigid structures: the clavicle, pelvis and rib cage. Because they are rigid and
stop lower than the shoulders, shield systems are expected to interact very differently
with the child. They could mainly load ribcage and abdomen. In principle it is possible
to design them in way that they are also loading the pelvic bone in order to prevent
abdominal loading but this does not always seem to be the case.
 32 children involved in a frontal or lateral accident in the CASPER accident database
were using such a system. However, 90% of them children were from the CREST
project (1996 to 2000), and so were using older child restraints in older cars.
 5 were not injured, 14 slightly injured, 4 sustained moderate injuries, and the
remaining 9 suffered serious or worse injuries. Head injuries were the most common,
followed by chest and the spinal injuries. The neck represented ‘a non-negligible’ part
of severe injuries in shield systems, their outcomes being similar to the ones
observed for harness systems. Injuries to limbs were less frequent than with other
restraint systems. Rib fracture was a more common chest injury pattern for shield
systems.
46
Misuse analysis
 There was only one shield system, which was being used correctly, in the CASPER
misuse studies. There was also only one shield restraint in the Belgium database, but
it was used without shield. The number of cases is too small to draw any conclusion,
except that shield systems are seldom observed in the three CASPER study regions
and Belgium.
 Based on the data that was analysed, the consequences of the current revival of
shield systems on child protection cannot be determined with certainty. No clear
benefit could be established and potential risks have been identified. It is also unclear
if test procedures are sufficient for the evaluation of shield systems real world
protection. Caution should therefore be exercised with these systems and studies
should be performed to understand and detect as early as possible potential real
world issues.
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Seat belt misuse among children transported in belt-positioning
booster seats
J O’Neil, D. M. Daniels, J. L. Talty and M J. Bull
Accident Analysis & Prevention, Volume 41, Issue 3, May 2009
http://www.sciencedirect.com/science/article/pii/S0001457509000074
To observe and report seat belt use among children younger than 16
years in belt-positioning booster seats.
A cross-sectional, observational survey of children transported in motor
vehicles between 2006 and 2007 at 25 fast food restaurants and
discount department stores throughout Indiana.
Key Findings:
 Overall, 1,446 drivers participated, 2,287 children were observed with 564 children in
belt-positioning booster seats.
 At least one seat belt misuse was observed for 64.8% of the children transported.
 Common misuses were the shoulder belt being placed over the booster seat armrest
(35.8%); shoulder belt not at mid-shoulder position (28.5%), seat belt was too loose
(24.5%), and the shoulder belt was either behind the child's back (9.1%) or under
their arm (10.0%).
 There is a high frequency of seat belt misuses among children transported in booster
seats. Advice to parents on appropriate car seat selection, and encouragement to
parents to supervise seat belt use may decrease misuse.
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Methodology:
Report on Relevant Children Injury in Road Accidents and
Specification of Children Models
P Lesire, F Cassan, J Yang, S Huang, R Willinger, M Frank, P Beillas,
C Rodarius, H Johannsen and A Eisenach
CASPER Project Deliverable D.2.1.1, 2010
http://cordis.europa.eu/publication/rcn/14511_en.html
To identify the various child injury mechanisms in frontal and lateral
collisions and to determine the associated physical parameters.
Analysis of accident databases and results from previous research on
child safety.
Key Findings:
 Carrycots (Group 0): The number of crashes with carrycot type restraints was too low
to draw conclusions.
 Rearward-facing Infant Carriers (Group 0/)+): Offer good protection in frontal impacts.
But severe head injuries are most common injuries, suggesting more effective
padding would reduce risk. Limb injuries also common.
 Rearward-facing systems with harness (Group 1) – more popular in Northern Europe,
with some evidence they are more effective in frontal impacts than forward-facing
seats. Severe head injuries less common than with forward-facing infant carriers.
 Forward-facing Systems (Group 1): Head injuries most common. Neck injuries not
common, but protection important. Chest and abdominal injuries infrequent, but can
be caused by high forces from the harness and its buckle, especially if child’s
shoulders slip out of harness.
 Forward-facing Systems with shields (Groups 1 & 2): No accident data available, but
head contact with the top of the shield and risk of (total or partial) ejection possible.
 Forward-facing Seats and adult seat belt (Booster seats) (Groups 1/2/3): High risk of
neck injury for young children using these type of restraint.
 Booster seats and adult seat belt (Groups 2/3): Head most often injured, but
abdominal injuries also more common, especially from high forces caused by the seat
belt. Limb injuries also more common.
 Booster cushions and adult seat belt (Groups 2/3): Similar injury pattern to booster
seats, but more chest injuries, probably because these used by older children.
 Adult seat belts: Use of seat belts instead of a child restraint ‘not negligible’. Similar
injury patter to booster cushions, but more severe injuries, especially to the abdomen.
 Fewer side impacts in database mean same level of analysis not possible. But
children in restraints more likely to be uninjured or only slightly injured in side impacts
than children using the adult seat belt. The level of intrusion is a key determining
factor.
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Methodology:
Belt-positioning booster seats and reduction in risk of injury
among children in vehicle crashes
Durbin DR, Elliott MR, Winston FK
Journal of the American Medical Association
JAMA; 289(21): 2835-40, 4 June 2003
http://jama.ama-assn.org/content/289/21/2835.full.pdf+html
To quantify the association of belt-positioning booster seats compared
with seat belts alone and risk of injury among 4 to 7 year-old children
and to assess patterns of injury among children in booster seats vs seat
belts.
Cross-sectional study of children aged 4 to 7 years in crashes of
insured vehicles in 15 states, with data collected via insurance claims
and a telephone survey. A probability sample of 3,616 crashes
involving 4,243 children weighted to represent 56,593 children in
48,257 crashes was collected between 1 December 1998 and 31 May
2002.
Key Findings:
 Although more than a dozen states have ratified laws that require booster seats for
children older than 4 years, most states continue to have child restraint laws that only
cover children up to age 4 years.
 Lack of booster seat effectiveness data may be a barrier to the passage of stronger
child restraint laws.
 Injuries occurred among 1.81% of all 4 to 7 year-olds, including 1.95% of those in
seat belts and 0.77% of those in belt-positioning booster seats.
 The odds of injury, adjusting for child, driver, crash, and vehicle characteristics, were
59% lower for children aged 4 to 7 years in belt-positioning boosters than in seat
belts.
 Children in belt-positioning booster seats had no injuries to the abdomen, neck,
spine, back, or lower extremities, while children in seat belts alone had injuries to all
body regions.
 Belt-positioning booster seats were associated with added safety benefits compared
with seat belts to children up to age 7 years, including reduction of injuries classically
associated with improper seat belt fit in children.
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Minimizing the Risk of Lap/Shoulder Belted Children Submarining
the Lap Belt in Frontal Crashes
G R Whitman, A V Hart, III, L Sicher, Bn Benda, L A D’Aulerio
International Technical Conference on the Enhanced Safety of Vehicles
(ESV) 23rd Conference, Paper Number 13-0041, 2013
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv23/23ESV-000041.pdf
To determine whether belt-positioning-booster seats incorporate seat
bottom design features, identified by previous research, to minimize the
risk of submarining.
The booster seats were evaluated through inspection and testing.
Methodology:
Key Findings:
 The majority of Belt-Positioning Booster seats (BPBs) now incorporate seating
surfaces with low compressibility, anti-submarining seat ramps and lap belt guide
hooks. These features combine to minimize the potential for submarining.
 However, two of the BPBs evaluated had very little or no seat ramp and, therefore,
did not provide any significant restraining load to the pelvis. One of those two BPBs
also had an extremely compressible seating surface.
 Previous research indicates that these deficiencies significantly increase the potential
for submarining.
 Published epidemiology studies indicate that BPBs generally reduce the rate of injury
to children in crashes compared to children using only the adult seat belt. However,
children continue to sustain “seat belt syndrome” injuries.
 Research has determined that seat design is critical to avoid submarining the lap belt
and preventing seat belt syndrome injuries.
 Children are especially vulnerable to submarining the lap belt. Yet, there are no
requirements to ensure that BPBs incorporate features that have been identified as
critical to avoid submarining the lap belt during frontal crashes. BPB manufacturers,
automobile manufacturers, and NHTSA must work together to establish requirements
that will ensure that the BPB will work properly with motor vehicle seat belts to
prevent submarining and its associated injuries.
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Methodology:
Literature Review, Accident Analysis and Injury Mechanisms
C Visvikis, M Pitcher, B Girard, A Longton and M Hynd
EPOCh, Enabling Protection for Older Children, Final Project Report
218744, 2009
http://www.epochfp7.org/Publications.aspx
To examine how and where older children are injured when travelling in
vehicles and to establish the main priorities for body areas that need to
be protected by restraints systems, and to identify requirements for the
child crash test dummy.
Analysis of the CCIS database for injuries suffered by 6 – 12 year old
children in moderate to severe collisions.
Key Findings:
 None of 6 – 12 year old children in moderate to severe collisions in frontal collisions
who were in booster seats suffered moderate or severe injuries, unlike those who
were unrestrained, using an adult seat belt or a booster cushions.
 However, the numbers were too few to draw conclusions.
 None of the children in side impact collisions who were using booster seats or
booster cushions suffered moderate or severe injuries, but again, the numbers were
too few to draw conclusions.
 In front impacts, head injuries are the most common, followed by the abdomen, often
due to the child ‘submarining’ under the lap belt because it is not positioned correctly
on the child’s pelvis.
 Chest injuries less common for children using booster seats than those using booster
cushions or just the adult seat belt, possibly because booster seats help to position
the seat belt correctly and securely.
 Upper and lower limb injuries are frequent, normally caused by impacts with rigid
parts of car interior.
 In side impacts, head injuries also most common, followed by chest and abdomen
injuries. Upper and lower limb injuries frequent, normally caused by impacts with rigid
parts of car interior or intruding objects.
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Interventions for promoting booster seat use in four to eight year
olds travelling in motor vehicles
Ehiri JE, Ejere HOD, Magnussen L, Emusu D, King W, Osberg SJ,
The Cochrane Collaboration, 2009
http://www.thecochranelibrary.com/userfiles/ccoch/file/Safety_on_the_r
oad/CD004334.pdf
To evaluate the effectiveness of interventions to promote the use of
booster seats.
A systematic review of studies of interventions to promote the
acquisition and use of booster seats.
Key Findings:
 Public health and traffic safety agencies recommend the use of booster seats by
children until the vehicle seat belt fits properly; typically when the child is at least 58
inches tall, has a sitting height of 29 inches and weighs about 80 pounds.
 In children aged 4 to 7 years, booster seats are estimated to reduce the odds of
sustaining clinically significant injuries during a crash by 59%, when compared to
using ordinary vehicle seatbelts.
 Despite the effectiveness, many children are not restrained in age-appropriate
booster seats.
 The authors found five studies involving a total of 3,070 participants. All the
interventions investigated were found to increase the use of booster seats, compared
to groups receiving no intervention.
 The distribution of free booster seats combined with education on their use, had a
marked beneficial effect, as did incentives (for example, booster seat discount
coupons or gift certificates) combined with education.
 Education-only interventions also produced beneficial outcomes.
 One of the studies evaluated the effectiveness of the enforcement of a booster seat
law, but did not detect an effect on usage.
 The current evidence suggests that several types of interventions designed to
increase the use of booster seats among children aged four to eight years, are
effective.
 However, there is still a need for further high quality trials, especially those conducted
outside of the USA and Australia, where current research dominates.
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Methodology:
Effects of seating position and appropriate restraint use on the
risk of injury to children in motor vehicle crashes
Durbin DR, Chen I, Smith R, Elliott MR, Winston FK
American Academy of Pediatrics
Pediatrics 115(3):e305-9, March 2005
http://www.ncbi.nlm.nih.gov/pubmed/15741356
To evaluate the relationship of seating position and restraint status to
the risk of injury among children in passenger vehicle crashes.
A cross-sectional study of children under 16 years old who were
involved in crashes of insured vehicles in 15 states, with data collected
via insurance claims records and a telephone survey. A probability
sample of 17,980 children in 11,506 crashes, representing 229,106
children in 146,613 crashes, was collected between December 1, 1998,
and November 30, 2002. Parent reports were used to define restraint
status, seating position, and occurrence of clinically significant injuries.
Key Findings:
 Many states are upgrading their child restraint laws to include provisions for the use
of age-appropriate restraints for 6 to 8 year olds, with some also requiring children to
sit in the rear.
 Approximately 62% of children use seat belts, 35% use child restraints, and 3% use
no restraint.
 Nearly 4 in 5 children sit in the rear seat, with half of children being restrained
appropriately for their age in the rear, although this varies according to age.
 Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and
84.9% did not have any injury.
 Unrestrained children in the front are at the highest risk of injury and appropriately
restrained children in the rear are at the lowest risk, for all age groups.
 Inappropriately restrained children are at nearly twice the risk of injury, compared with
appropriately restrained children.
 Unrestrained children were at more than 3 times the risk.
 The effect of seating row is less than the effect of restraint status; children in the front
seat are at 40% greater risk of injury, compared with children in the rear seat.
 Had all children in the study population been appropriately restrained in the rear seat,
1,014 serious injuries would have been prevented.
 Age-appropriate restraints confer relatively more safety benefit than rear seating, but
the two work synergistically to provide the best protection for children in crashes.
 These results support the current focus on age-appropriate restraint in recently
upgraded state child restraint laws. However, considerable added benefit would be
realised with additional requirements for rear seating.
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Seating Patterns and Corresponding Risk of Injury Among 0 to 3
Year-Old Children in Child Safety Seats
M J. Kallan MS, Dennis R. Durbin MD, MSCE & Kristy B. Arbogast PhD
American Academy of Pediatrics
Pediatrics Vol. 121 No. 5, May 1, 2008
http://pediatrics.aappublications.org/content/121/5/e1342.abstract
To describe seating position patterns among appropriately restrained
child occupants aged 0 to 3 years in the rear of vehicles, and to
determine the association between rear seating and risk of injury.
Analysis of data collected, via insurance claim records and a validated
telephone survey, of child occupants aged 0 to 3 years seated in a
child-restraint system in the rear of a vehicle manufactured in or after
1990, involved in a crash in 16 states between 1 December 1998 and
31 December 2006.
Key Findings:
 Seating position distribution for child occupants was left outboard (31%), center
(28%), and right outboard (41%).
 There was an inverse relationship between the center position and increasing child
age (39% for occupants under 1 year old versus 18% for occupants 3 years old),
independent of the number of additional row occupants.
 Child occupants seated in the center had an injury risk 43% lower than children
seated in either of the rear outboard positions.
 The most common seating position for appropriately restrained child occupants in a
child-restraint system is the right rear outboard.
 The center rear seating position is used less often by children restrained by a childrestraint system as they get older.
 Children seated in the center rear have a 43% lower risk of injury compared with
children in a rear outboard position.
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Comparison of motor vehicle occupant injuries in restrained and
unrestrained 4 to 14 year-olds
Agran PF, Castillo DN, Winn DG
Accident Analysis Prevention, 24(4):349-55, August 1992
http://www.ncbi.nlm.nih.gov/pubmed/1605817
To compare the injuries suffered by restrained and unrestrained 4 to 14
year old children involved in road accidents.
Comparison of injuries of restrained and unrestrained 4 to 14 year-olds
in nine emergency rooms and the Coroner's office in Orange County,
California from 1983 to 1989.
Key Findings:
 Analyses were performed separately for 4 to 9 and 10 to 14 year-olds because of
differences related to the fit of the seat belt.
 Significantly fewer intracranial injuries and a significantly lower mean Injury Severity
Score (ISS) were seen between restrained and unrestrained 10 to 14 year-olds in the
front passenger and back seats. But for 4 to 9 year-olds in the back seat only.
 These same differences were noted between restrained 4 to 9 year-olds in the back
compared with those in the front passenger seat.
 Except for 4 to 9 year-olds in the front passenger seat, the findings are consistent
with similar studies of occupants of all ages.
 The results suggest that lap-shoulder belts (primary restraint in front seat) may
provide less protection for 4 to 9 year-olds than for 10 to 14 year-olds and adults.
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Methodology:
Some aspects of the safety of children as car passengers in road
traffic accidents
Claes Tingvall
Acta Paediatric, Volume 76, Issue Supplement s339, pages 1–35,
October 1987
http://onlinelibrary.wiley.com/doi/10.1111/j.16512227.1987.tb10586.x/abstract
To investigate child safety in cars including the epidemiology of child
injuries and injury assessment, restraint use effectiveness, restraint use
limitations and improper use of child restraints.
Literature review, questionnaire survey, observational studies,
laboratory crash tests.
Key Findings:
 Child restraint use, especially the use of rearward-facing restraints, is effective in
reducing injuries.
 Using injuries occurring in spite of restraint use were often minor in terms of fatality
risks, but injuries to the neck and head may cause long-term consequences.
 The police were found to report only slightly more than half of the injured children
reported to the insurance company.
 Misuse of child restraints was found to decrease the effectiveness restraint use or
induce injuries.
 On the basis of these studies it is recommended that child restraints be incorporated
into cars as an in-built system with the same basic design as restraints that are
available as extra equipment.
 Certain considerations should be paid, however, to those injuries occurring among
restrained children that entail a risk of medical disability.
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Methodology:
Motor Vehicle Childhood Injuries Caused by Noncrash Falls and
Ejections
Phyllis F. Agran, MD, MPH; Debora E. Dunkle, PhD; Diane G. Winn,
RN, MPH
Journal of the American Medical Association
JAMA;253:2530-2533, 1985
http://www.ncbi.nlm.nih.gov/pubmed/3981781
To describe the patterns of passenger travel, precipitating causes, and
severity of injury in non-crash falls or ejections.
Analysis of data from a larger ongoing hospital-based monitoring
system of a sample of children aged 0 to 14 years who were treated for
injuries incurred in a motor vehicle accident.
Key Findings:
 In a sample of children aged 0 through 14 years who were treated for injuries incurred
in a motor vehicle accident, a large proportion of those involved in non-crash events
fell or were ejected from the vehicle.
 Over 50% of those ejected sustained serious injuries compared with 5% of those who
remained in the vehicle.
 Two high-risk patterns emerged:
(1) the young child traveling in a passenger seat falling out of the vehicle, and
(2) the older child riding on the exterior of the vehicle and falling off during a vehicle
maneuver.
 Door locks, restraint use, and prohibition of travel in non-passenger locations would
prevent these serious non-crash injuries.
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Methodology:
Injuries Among 4 to 9 Year-Old Restrained Motor Vehicle
Occupants by Seat Location and Crash Impact Site
Phyllis Agran, MD, MPH; Diane Winn, RN, MPH; Debora Dunkle, PhD
American Journal of Diseases of Children
Am J Dis Child;143(11):1317-1321, 1989
http://archpedi.ama-assn.org/cgi/content/abstract/143/11/1317
To examine patterns of injury among restrained 4 to 9 year-olds by seat
location and crash impact site.
Analysis of data from a hospital-based monitoring system of 4 to 9 year
old children injured in a motor vehicle accident.
Key Findings:
 Having outgrown their child safety seats, 4 to 9 year-old children are often placed in
adult seat belts.
 77% of the sample sustained a head or face injury.
 Upper-torso and extremity injuries were infrequent.
 Lower torso injuries occurred primarily in frontal impacts in both the back and front
seats.
 Frontal impacts resulted in a greater proportion of serious injuries than rear impacts.
 The most serious injuries, however, occurred to children seated on the side of impact
in lateral collisions.
 Questions must be raised regarding the appropriateness of current restraint system
for young children.
 Technological improvements in vehicle design and belt systems are needed to
improve protection, particularly in lateral impacts.
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Methodology:
Rear seat safer: Seating position, restraint use and injuries in
children in traffic crashes in Victoria, Australia
Alexia Lennon, Vic Siskind, & Narelle Haworth
Accident Analysis & Prevention, Volume 40, Issue 2, pp 829–834,
March 2008
http://www.sciencedirect.com/science/article/pii/S0001457507001741
To calculate relative risks of death or serious injury for children (0–3
years, 4–7 years; 8–12 years) travelling in passenger cars.
Analysis of data from 30,631 Victorian crash records to calculate
relative risks of death or serious injury for children (0–3 years, 4–7
years; 8–12 years) travelling in passenger cars during 1993–1998 and
1999–2004.
Key Findings:
 Car crashes are a major cause of death and serious injury to children but most
analyses of risk are based on USA data.
 The Australian context is different in at least three ways: (1) the proportion of
passenger-side airbags, a potential risk to children in front seats, is much lower; (2)
unlike in the US, Australian airbags are designed to work with restrained passengers;
(3) restraint use for children 0–12 years is high (>90%).
 Over 90% were reportedly wearing a restraint, and 20% were travelling in the front
seat.
 For children under 4 years travelling in the front seat, the relative risk of death was
twice as great than when travelling in the rear, and the risk of serious injury was 60%
greater.
 The relative risk of death whilst travelling in the front seat was almost four times
greater for children aged under 1 year.
 Serious consideration should be given to mandating rear seating for children,
particularly those aged 4 and under.
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The safest seat: Effect of seating position on occupant mortality
James Mayrose & Aruna Priya
Journal of Safety Research Volume 39, Issue 4, Pages 433–436, 2008
http://www.sciencedirect.com/science/article/pii/S0022437508001011
To investigate the survival rates of occupants of passenger cars
involved in a fatal crash between 2000 and 2003.
Methodology: Univariate and a full logistic multivariate analysis of data from every fatal
crash in the United States between 2000 and 2003.
Key Findings:
 The rear middle seat is safer than any other occupant position when involved in a
fatal crash.
 Overall, the rear (2nd row) seating positions have a 29.1% increased odds of survival
over the first row seating.
 The rear middle seat has a 25% increased odds of survival over the other rear seat
positions.
 After correcting for potential confounders, occupants of the rear middle seat have a
13% increased chance of survival when involved in a fatal crash than occupants in
other rear seats.
 The safest position for any occupant is the rear middle seat.
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Methodology:
The effect of seating location on the injury of properly restrained
children in child safety seats
Ulric J. Lund
Accident Analysis & Prevention, Volume 37, Issue 3, Pages 435–439,
May 2005
http://www.sciencedirect.com/science/article/pii/S0001457504001204
To assess the effect of seating position on the risk of injury, and whether
the center rear seat is a safer position than either of the outboard rear
seats.
Analysis, using a multiple logistic regression model, of children seated in
a child safety seat in a rear seat location using data from the National
Automotive Sampling System (NASS), General Estimates System (GES)
Key Findings:
 The center rear seat is not a safer seating position than either of the outboard rear
seats in terms of odds of injury.
 These results do not agree with those of previous studies that suggested the center
rear seat is the safest position for parents to place a child safety seat.
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Restraint use by car occupants, 2006-2008. Leaflet LF 2106
TRL Ltd
TRL, December 2008
https://trl.co.uk/reports/LF2102
To monitor the effects of changes made in September 2006 to the
regulations governing the use of restraints by child passengers.
Observational surveys at six monthly intervals from October 2006 to
October 2008 of the use by car occupants of seat belts and other
restraint systems at 32 sites chosen to represent all types of road.
Key Findings:
Although the results may not be strictly nationally representative, they give useful insights
into national patterns of restraint use.
Table 5: Use of restraints by younger children (%), October 2008
Front seat passengers
Rear seat
passengers
1–4 years
5–9
1–4
5–9
old
years old years old years old
Seat belt worn
20
71
5
51
Child seat used
53
0
75
6
Rear facing child seat used
0
0
1
0
Booster seats & cushions used:
Properly
21
28
18
37
Wrongly
0
0
0
0
Unrestrained: on seats
5
1
1
6
on passenger’s lap
1
0
1
0
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National Database for Child Restraint Use
Mark Pitcher, Marianne Hynd and James Onyekwere
TRL Limited
Not available online
To develop a standardised form to collect details of restraint use and
fitting from Child Car Seat Checks run by local authorities and others,
and analyse the data to identify common problems.
Methodology:  Survey to develop a standardised form to record details of the type of
restraint, the child using it, the way in which it is fitted, including
incorrect fittings.
Key Findings:
 Many ‘Inspection Clinics’ (under various names) are run across Britain to which parents
are able to bring their child restraint, ideally in their car and with the child who uses it, to
a convenient location (such as a supermarket car park) where the restraint is checked
by an expert to assess whether it is suitable for the child, for the vehicle and whether it
is fitted correctly.
 An initial analysis of the data illustrated that 43% of parents did not know the weight or
height of their child, information that is crucial when choosing a child car restraint.
 Although the appropriateness of the child restraints being used was generally good,
there was a trend to use forward-facing child restraints as soon as possible, and
sometimes too soon, with some being used by children under 9 months.
 A trend to transfer children to booster seats as soon as possible was also seen, with a
large percentage of 3 year-olds using them.
 Most child restraints were compatible with the vehicle in which they were used, but only
53% were correctly installed, usually because the seat belt was too slack or incorrectly
routed.
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Overview Report of Research into the Incorrect Use of Child
Restraints in Selected Countries
C Willis, M Le Claire and C Visvikis (TRL) A Kirk and R Grant (VSRC)
EU Child (Child Injury Led Design) Project, 2006
https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/14369
To improve the knowledge of child biomechanics and injury tolerance
by reconstructing real accidents with a crash test dummy.
Literature Review
Methodology:
Key Findings:
 Most countries mandate the use of child restraints but there are often gaps and
exceptions, particularly as children get older.
 However, research shows that the majority of children are not restrained correctly
and even with the most appropriate restraint for a child’s size, the way it is used can
affect its performance, possibly resulting in serious injury and death.
 In the UK the percentage of correctly fitted child restraints is low, but use is high.
Parents are often not confident that their child is restrained correctly. Studies also
show that instructions given with child restraints need to be clearer to increase the
likelihood of correct fitting and parent confidence. Some child restraints are bought
second hand and so may not provide the best protection for the child.
 In the USA as many as 80% of child restraints are misused in some way, including
incorrect fitting, facing the wrong direction, the child not being properly secured in the
restraint and not ensuring the child restraint is the correct type and size for the child.
Interviews with parents suggest that most do not have a good understanding of the
installation and use of child restraints and of those that do. There is a link between
demographic factors, such as academic achievement or socioeconomic status, and
misuse.
 Two groups of children are most at risk when not restrained properly: infants using
forward facing child restraints when they are less than one year old, and children
using the seat belt when they should be using a forward facing seat or booster seat.
Child restraint misuse is associated with greater injury severity, especially more head
injuries. However, the risk of sustaining injuries from misused or inappropriate child
restraints is less than the risk of sustaining multiple serious injuries from travelling
unrestrained.
 The major problem in Spain is lack of restraint use in general.
 In Sweden 83% of children always use a seatbelt. However, the restraint use is not
always correct or appropriate. Children under 3 should travel rear facing but one
study found nearly 30% travelling forward facing. Another study showed that whilst
the majority of parents believe their child to be correctly restrained, only 60% fully
understood the correct restraint to use for their child and how to fit it.
 In France, 73% of child restraints were misused in some way. Parents find child
restraints difficult to install, second hand child restraints are used, parents take less
care installing them for short trips and allow children to adopt a more comfortable
position for long trips especially in the evening. The most common types of misuse
were slack in the harness, slack in the seat belt and misrouting of the seat belt.
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Methodology:
Childhood Crash Injury Patterns Associated with Restraint
Misuse: Implications for Field Triage
Eileen M. Bulger, MD; Robert Kaufman, BS; Charles Mock,MD, PhD1
Prehospital and Disaster Medicine, 2008;23(1)
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.176.910&rep
=rep1&type=pdf
To describe the injury patterns associated with restraint misuse in the
pediatric population, with particular focus on clues to significant injury
that can be identified by the pre-hospital provider that may impact
subsequent triage decisions.
A case series presentation that illustrates the injury patterns associated
with various types of restraint misuse in infants (ages 0–1 years),
toddlers (age 1–4 years), young children (ages 4–8 years), and preteens (ages 8–14 years). Cases were identified from the Crash Injury
Research and Engineering Network (CIREN) database.
Key Findings:
 Restraint misuse is a common problem leading to increased morbidity and mortality
for children involved in motor vehicle crashes.
 Six cases are presented that illustrate the injury patterns associated with misuse of
rear-facing infant car seats, forward-facing child seats, booster seats, and shoulder
belts.
 Emergency medical services providers need to be aware of these issues when
assessing children and determining appropriate triage to a trauma center.
 Ongoing educational efforts also are vital to inform parents about the risks of
inappropriate restraint use and to encourage legislators to better define appropriate
restraint use for older children.
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Methodology:
A Review of Child Car Restraint Instructions
RoSPA
RoSPA, March 2001
http://www.rospa.com/rospaweb/docs/advice-services/roadsafety/practitioners/carseats-instructions-review.pdf
To examine the role of instructions in the fitting of child car restraints.
A review of manufacturer’s instructions for a selection of child car
restraints available in Britain, and observational surveys of volunteers
fitting the restraints using the instructions.
Key Findings:
 Many people find fitting child restraints difficult. Some major retailers have trained
staff who are able to help, and many manufacturers operate helplines and websites.
However, problems persist.
 There is wide variety in the quality of the instructions provided with child restraints,
some of which are well-written and presented with good, clear illustrations. However,
others are very poor in these respects.
 Generally, the volunteers found the booklets daunting because of the amount of
information, and so expected to find fitting the restraints difficult.
 Small print size and the need to cross refer between pages within the booklets
caused particular problems and complaints. The volunteers felt that placing diagrams
and supporting text together was the most helpful layout.
 When studying the instructions, most people focussed mainly on the diagrams.
However, the quality of illustrations in the instruction booklets was very variable.
 Volunteers generally gave lower scores for the text than the diagrams. Many
commented that there was too much text, and sometimes they felt much of it was
irrelevant or unnecessary. A frequent comment was that it was difficult to isolate the
essential information from the non-essential.
 Some instruction booklets were printed on flimsy paper and quickly became
crumpled, suggesting that they would not last very long. On-product instructions
were often not seen, and in some cases had begun to peel off.
 The project also identified a number of common fitting problems, especially failures to
ensure the restraint was tightly secured, which are worthy of further research.
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THINK! Road safety campaign evaluation October 2006: Post Child
Restraints and Pre Mobiles
DfT Communications Directorate
Department for Transport, 2006
http://webarchive.nationalarchives.gov.uk/+/http://think.dft.gov.uk/pdf/33
2982/332986/200610b.pdf
To measure the effectiveness of a national publicity campaign to raise
awareness of new legislation governing the use of child restraints.
Pre and Post interview survey.
Methodology:
Key Findings:
 63% of drivers used a child restraint when transporting a child, an increase from 50%
at the pre-stage.
 Use of child restraints decreased as the age of the child increased.
 Amongst those who did not use child restraints, half stopped when the child was aged
between 4 and 7 years, mainly due to the height or size of the child.
 Six in ten (58%) of those who carried children aged 11 or under in the previous 6
months were aware that children could legally stop using restraints when aged over
11, an increase from 20% in July. However, when asked at what height this was legal
only 13% said 135cm, although this was an increase from 2% in July.
 Total awareness (spontaneous and prompted awareness combined) of the legislation
had increased from 45% in July to 93% after the campaign.
 Amongst those aware of the legislation after prompting, a quarter had made changes
to the way they transported children, two thirds said they did not need to make
changes and one in ten had yet to make changes. The most commonly mentioned
change was for children to start using child restraints.
 Of the respondents who said they had not yet made changes, most did not actually
need to because they already used car seats/boosters or their child was too tall. 8%
said they do not usually carry children or only carried children occasionally, but 5%
said they were either unable or could not afford to purchase a seat/booster.
 Those not using child restraints are more likely to be those who transport older
children, and those who transport children less regularly, therefore further publicity
may be required to get the message across to these groups.
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Methodology:
Effectiveness of hands-on education for correct child restraint use
by parents
Karen Tessier
Accident Analysis and Prevention 42, 1041–1047, 2010
http://www.seatsforkidscanada.com/f/Effectiveness_of_handson_education_for_correct_child_restraint_use_by_parents.pdf
To evaluate whether a hands-on educational intervention makes a
significant difference in the proper use of a child passenger restraint by a
parent.
The clinical trial design included a sample of 111 parents who were at
least seven months pregnant and who were randomly assigned to one of
two groups (56 intervention and 55 control)
Key Findings:
 All participants received a free car seat and a standardized education session on the
safety and use of child passenger restraints.
 The experimental group received an additional component consisting of a hands-on
demonstration and return demonstration of correct installation and use in their own
vehicle. Follow-up observation for correctness of use was done after birth.
 A total of 24 (22%) parents correctly used the car seat; of these, 18 (32%) were in the
intervention group and 6 (11%) were in the control group.
 The intervention group was four times more likely to have correct use than the control
group.
 The range for the number of errors per person was 0–7, with the majority (70%) having
0–2. The rate of errors was 33% less in the intervention group. There were few serious
errors in either group.
 No secondary variable (age, education, income, or help from others) had a significant
effect on the outcome.
 The hands-on educational intervention made a significant difference in the proper use
of a child passenger restraint.
 This study demonstrates the value of hands-on teaching for learning how to correctly
install and use a child car seat.
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Title:
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Injuries in Children Aged 0–14 Years and Inequalities
Towner E, Dowswell T, Errington G, Burkes, M. and Towner J
Health Development Agency, 2004
http://www.nice.org.uk/niceMedia/pdf/injuries_in_children_inequalities.pdf
To describe and seek to understand how and why injuries
disproportionately affect some children more than others.
Systematic review of child injury and child injury prevention studies.
Methodology:
Key Findings:
 There are great variations in injury mortality and morbidity, reflecting children’s age,
gender, socio-economic group, cultural or ethnic group, and location.
 National injury data systems provide good information on age and gender and some
information on social and economic factors, but not on ethnicity or on vulnerable groups
such as children in homeless families or disabled children.
 The factors associated with injury inequalities are multifaceted and inter-related; the
causal pathways linking these factors to injury events remain uncertain.
 Three tiers of factors need to be considered to clarify the inter-relationships: (1)
proximate tier, immediate conditions that result in exposure to hazard; (2) intermediate
tier, eg childcare practices; (3) ultimate tier, the wider social, economic, political and
cultural processes.
 More direct causes of injury include exposure to hazards, the ability of parents, carers
and communities to protect children, and children’s ability to manage hazards.
 Greater knowledge about disparities between groups and factors leading to increased
risk is important in designing interventions.
 Few intervention studies explicitly address inequalities – and still fewer attempt to set
out the problem in relation to that factor, take it into account when designing the
intervention, and report on whether there has been any differential impact in relation to
that factor.
 Many interventions target specific age groups of children, but there are few examples of
results comparing the impact of an intervention on different age or gender groups.
 Interventions have increasingly been targeted at deprived individuals or groups – the
main strategy adopted in interventions is the provision of safety equipment.
 Cultural differences are rarely addressed (a few interventions involved the target group
in the design of the intervention), and few studies compare interventions in different
ethnic groups.
 When communities have been matched in controlled interventions, broad demographic
variables have been used and little attention has been paid to the context.
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Methodology:
Road Safety Research Report No. 123 “Road User Safety and
Disadvantage”
Clare Lowe, Grahame Whitfield, Liz Sutton and Jeremy Hardin
Department for Transport, February 2011
http://www.dft.gov.uk/publications/rsrr-theme1-road-user-safety/
To provide a practical overview of road safety issues in disadvantaged
areas, involving an exploration of the populations, environment,
behaviour, attitudes and perceptions of risk road safety provision, the
nature and extent of partnership working and the extent of community
involvement in road safety delivery.
Analysis of casualty and deprivation data, using STATS19 and Index of
Multiple Deprivation (IMD), a review of existing evidence, interviews
with road safety experts and government representatives from other
policy areas, a review of local data and policy and interviews with
representatives of local agencies in five case study areas; research
within the communities and in a relatively affluent area with a high
casualty rate for comparative examination of the risks and their
association with disadvantage.
Key Findings:
 There were limited number of road safety activities concerned with understanding the
specific needs of disadvantaged communities, and promoting behavioural changes in
response to these needs.
 However, where this did happen, they sought to address specifically identified
problems, provide worthwhile support to disadvantaged communities and potentially
contribute to reducing the differential risk of road accident injury.
 A leaflet on seat-belt wearing written in the specific languages where non-seat-belt
wearing was prevalent is one example of such practice.
 Another example was a resource containing casualty information specific to the local
area to raise awareness of the high level of child pedestrian casualties.
 The subsidy of child car seats, car seats for taxis from maternity wards and car seat
inspections were also interventions that demonstrated a recognition of the needs of
the target audience and a focus on promoting behaviour change.
 Road Safety Champions (a volunteer scheme), and other area-based community
development activities, are further examples of interventions that aimed to
understand communities and develop activities that were wanted by, and relevant to,
the people in the local area.
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Road Safety Research Report No. 97 “Widening the Reach of Road
Safety – Emerging Practice in Road Safety in Disadvantaged
Communities: Practitioners’ Guide
Michael Hayes, Elizabeth Towner, John Towner, Paul Pilkington and
Heather Ward
Department for Transport, October 2008
http://webarchive.nationalarchives.gov.uk/+/http:/www.dft.gov.uk/pgr/road
safety/dpp/neighbourhoodroadsafety/wideningthereach.pdf
To produce good practice guidance on the development and
implementation of schemes to reduce road casualties in the most
deprived areas through new, innovative approaches.
Good Practice Guide
Methodology:
Key Findings:
 In 2005 and 2006 Sandwell Metropolitan Borough Council and Salford City Council
conducted road safety interventions to supply and fit free baby seats to families from
disadvantaged areas. Similar schemes were run in Wigan and Bradford.
 Families in deprived areas received a voucher which was redeemable at a local retailer
of child car restraints, whose staff showed the parents how fit the seat.
 In one area, a check within six months of receiving the seat was conducted to check
that it had not been sold as soon as it was received.
 The schemes were expensive to run because of the cost of the seats, and so their
sustainability was questionable.
 Between 2004 and 2006, Nottingham City Council, Nottinghamshire Fire and Rescue
Service and Nottinghamshire Primary Health Care Trust ran a scheme to provide free
inspections of child car restraints, by trained fire officers, alongside an educational
campaign to provide advice. This followed a local survey which found that roughly 8 in
10 seats were incorrectly fitted.
 Initially, the scheme was confined to families in the deprived areas, but this target group
proved difficult to engage and uptake was poor, which was disappointing as anecdotal
evidence suggested that it was disadvantaged communities who drove the oldest cars
and carried most children, often without restraints.
 Due to low uptake, the project was opened to all people in the city who carried a child.
 There is little evaluation to show that such schemes are effective in reducing casualties
or improving child restraint use on a large-scale, which may reflect the lack of wellstructured evaluations rather than any ineffectiveness in the programmes.
 Such schemes cannot use changes in casualty numbers as the measure of success
because they are too low to allow meaningful before and after comparisons. But
measures, such as knowledge and behaviour, take-up of the scheme, amount of
publicity obtained in the local media can provide an indication of the success of the
scheme.
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Methodology:
Child Advanced Safety Project for European Roads (CASPER),
Better Knowledge and Better Tools To Improve the Real Protection
of Children In Cars
P Lesire, H Johannsen, R Willinger, A Longton, A Kirk, P Beillas and A
Fiorentino
International Technical Conference on the Enhanced Safety of Vehicles
(ESV) 23rd Conference, Paper Number 13-0426, 2013a
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv23/23ESV-000426.pdf
To synthesise the results obtained in the different parts of the EC
CASPER project and considers sociological approaches, technical
works, and field and accident data.
Review of Data from the CASPER, CREST and CHILD projects, and
EEVC WG 18, ISO/TC22/SC12/WG1 and NPACS, and new data from
collection of data specific to the different task topics.
Key Findings:
 Based on a detailed French study of in-car child deaths:
o For frontal impact fatalities, the priority is to improve the quality of use of restraint
systems. When the child is correctly restrained, very few fatal cases are observed
in conditions similar to the frontal test of the current regulation.
o In side impact, the current level of protection does not seem sufficient. The level
of intrusion and direct impacts with intruding objects are important for children on
the struck side.
o For roll-overs the priority is to protect children from being ejected from the car and
from projections inside of the car. The rate of correctly restrained children in this
type of fatal accident is very low in France, which indicates that existing systems,
when correctly used, could be preventing these fatalities.
o Rear impact remains rare.
 Based on studies in 3 regions (Berlin, Lyon and Naples):
o Misuse of child seats is still a widespread and serious problem.
o The main problems are not threading the vehicle seat belt correctly through the
child restraint, and the general installation of the child seat in the vehicle. Both
problems could be prevented by the use of ISOFIX.
o Less than 4% of restraints were fixed with ISOFIX in the vehicle, despite the fact
that around 50% of the vehicle fleet was equipped with ISOFIX anchorages in
2011. Comparisons between studies conducted in Lyon in 2003 and in 2011
showed the average rate of misuse was about 71% in 2003 and 65% in 2011.
o The main differences were with forward facing systems with an integral harness,
the use of which was better in 2011 than in 2003, with a decrease of serious
misuse, such as incorrect harness use.
o For booster seats, the most frequent misuse was the same in 2011 as in 2003,
with the lower belt guides often not used and the chest part of the seatbelt under
the arm.
o Factors, such as the available time and the trip purpose, influenced how well
parents secured their children; they want to secure their child correctly, but it
needs to be easier and simpler to fit and use child seats.
Inappropriate use
 Comparisons between studies conducted in Lyon in 2003 and in 2011 showed that the
main problem continued to be moving a child into the next type of child restraint too
early with similar patterns in 2003 and 2011.
 Most of the mis-use problems could probably be reduced by providing better help and
guidance top parents.
 An additional study in Belgium in 2011 illustrated the same tendencies as in the other
studies:
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o many children not correctly restrained
o child restraint use being much lower for children older than 6 years
o too many parents not being aware that they are not using child restraints properly.
 For the first time the number of ISOFIX systems was large enough to compare with
“classical attachment CRS”:
o The rate of misuse with ISOFIX systems was 2.3 times lower than with the
“classical” ones.
o It was almost 3 time slower for forward-facing ISOFIX restraints than for forwardfacing child seats that are fitted with the vehicle seatbelt.
o The difference in the rate of misuse for booster seats with ISOFIX anchorages
compared with standard booster systems was smaller, but still apparent.
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Title:
Author:
Published:
Link:
Objectives:
Methodology:
Safety Benefits of the New ECE Regulation for the Homologation
of CRS - An Estimation by the EC CASPER Project Consortium
P Lesire, R Krishnakumar, M C Chevalier, H Johannsen, G Müller, A
Longton and A Kirk
International Technical Conference on the Enhanced Safety of Vehicles
(ESV), 23rd Conference, Paper Number 13-0431, 2013b
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv23/23ESV-000431.pdf
To develop a new regulation for child restraint systems that will
eventually replace the current ECE Regulation 44.
Review of the work of the EC-funded EPOCh and CASPER projects,
working groups such as EEVC WG12 and WG18 and research projects
in the child safety areas.
Key Findings:
 In Germany, 1 year old children are at greatest risk, probably due to changing too
early from rear facing to forward facing child restraints. In Sweden this change occurs
much later, i.e. with an age of 2 to 4 years. However, the national data used for this
analysis is too general to prove this theory.
 Of 206 fatally injured children aged 12 years or under, 57% were using a restraint
system and 31% were not restrained. The information was unknown for the remaining
12%.
 Field studies in France found that more than two thirds of children were not correctly
restrained in cars.
 Data from the CASPER project, showed that frontal impacts remain the primary
accident configuration in terms of killed children, with approximately one third of the
total, followed by side impacts that represent 28% and rollovers with 18%.
 Of these 206 children, 99 were using an appropriate child restraint, 66 of whom
showed no evidence of misuse. This makes a maximum rate of 32% of children
correctly restrained.
 Analysis of 894 child car passengers under 12 years old in the GIDAS (German In
Depth Accident Study) database between 1999 and 2008 found that 417 of the 894
children were involved in a frontal impact, 249 in a side impact (145 on the far side,
104 on the near side) and 228 in a rear impact. The number of seriously injured
children was low, indicating that the protection level is high in Germany, where nearly
all children are restrained when travelling in cars.
 Surveys in Naples, Berlin, Hannover and Lyon found only about one third of the
children were secured correctly. Comparisons with older misuse studies showed that
the rate of misuse has remained constant in the last 15 years.
 There are more problems with securing the child in the restraint than with the
installing the restraint in the car. However, the most common problems with
installation are seat belt path, and the lack of shoulder belt guide use in Groups 2/3.
These forms of misuse are critical and could lead to serious injuries if an accident
occurred.
 There is a big disparity in the weight of children according to their age. For example,
between 0 and 9 months of age, 40 % of children aged 0 to 9 months weigh between
9 and 13 kg and can legally travel in a forward-facing system.
 Globally about 27% of children are not using the appropriate restraint system for to
their weight.
 Globally, parents tend to change the restraint systems as soon as their children have
reached the lower limit of weight of the next size category. For example, 45% of the
children weighing less than 9 kg are transported forward facing, which represents a
high risk for them.
 30% of children weighing between 14 and 18kg are using a booster system while it
would be more appropriate for them to stay in a forward-facing seat with an integral
70
harness.
 A large number of parents also allow their children to use the adult seatbelt. Parents
need guidance.
 Nearly half of parents think that they never make mistakes in way they use restraint
systems, about a quarter feel they are doing something wrong but do not know
exactly what, and a quarter know that they are making mistakes.
 Only 2% of the parents had ISOFIX and 60% did not know about ISOFIX. In focus
groups, only 8% of the participants knew what ISOFIX is.
 The new regulation will improve the compatibility between child restraints and cars,
use test configurations that are more realistic and cover a larger range of impacts.
 The introduction of a dynamic side impact test in the regulation will allow the
coverage of most of the accident situations in which children can be still severely
injured.
 The promotion of ISOFIX systems will lead to better installation of child restraint
systems in cars, and parents want systems that are simpler to install.
 Information campaigns are needed in order that parents do not misunderstand the
reason for and the benefits of this new regulation.
Format: Pdf
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Author:
Published:
EEVC Working Group 18 Report: Child Safety
European Enhanced Vehicle Safety Committee
EEVC Working Group 18, February 2006
Link:
http://eevc.net/publicdocs/EEVC_WG18_REPORT_Child_SafetyFebruary_2006-1.pdf
To assess the effectiveness of child restraints in different types of
impact, to assess levels and types of child restraint mis-use and to
identify requirements for a child test dummy.
Literature review of national and European accident databases and
research studies
Objectives:
Methodology:
Key Findings:
 Very few accident databases record whether child casualties were using child
restraints suitable for their size and weight, nor whether they were fitted correctly.
 However, surveys consistently record high levels of misuse of chid car restraints.
 One European report found that 60% of restraints were installed satisfactorily, 21%
had major misuse problems and 16% were not compatible with the car in which they
were fitted.
 Frontal impacts account for about 50% of accidents involving children in cars, with
side impacts representing about 25%.
 Forward-facing seats are distinctly more effective in frontal collisions than in side
impacts.
 Although the number of side impacts in the database was small, head injuries
accounted for 62% of all severe injuries in all types of restraint, indicating that the
level of head protection was insufficient.
 Severe chest and abdomen injuries also occurred, mainly in children using a booster
seat or booster cushion, or just using the adult seat belt. These injuries were rarely
seen in children using a restraint with a shell (rearward- and forward-facing seats).
 20% of the children involved in side impact collisions suffered severe injuries and
43% minor injuries.
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Title:
Author:
Published:
Link:
Objectives:
The protection of children in cars - final report, TRL Report 458
Lowne, RW,Le Claire, M,Roberts, AK
TRL Ltd, January 2000
https://trl.co.uk/reports/TRL458
To improve the safety of children in cars by developing a dedicated child
restraint attachment system (ISOFix) and a side impact test procedure for
child restraints.
Methodology: Review of accident studies, laboratory tests.
Key Findings:
 The analyses all confirm the benefits of using child restraints.
 There is a need to provide improved protection in side impacts and to avoid loading from
luggage by improved seat strength.
 An experimental sled-based method for evaluating the performance of child restraints,
under side impact conditions, was developed. The method replicates the essential
interactions in a real car impact.
 Tests with this experimental arrangement demonstrated that this was a practical way to
evaluate the performance of child restraints under side impact conditions.
 ISOFix with two rear rigid attachments together with an anti-rotation system, such as a
top tether, would provide a good basis for a universal system with greatly reduced
misuse rates and an improved dynamic performance in accidents.
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Title:
Author:
Published:
Link:
Two thirds of child car seats not fitted correctly
AA and Britax
AA, 16 Feb 2009
http://www.theaa.com/motoring_advice/child_safety/aa-launches-range-ofaa-approved-britax-isofix-child-car-seats.html
To assess the level of correct and incorrect use of child car restraints.
Opinion Survey from 16,500 respondents.
Objectives:
Methodology:
Key Findings:
 Only a quarter of all people admitted experiencing difficulty in fitting a child car seat
despite evidence that two thirds of seats are not fitted correctly.
 66% of respondents stated that they did not know that the law requires children up to
the age of 12 to use a car seat and 80% of them were not aware that UK law requires
children under the height of 135cms to use a child seat.
 Grandparents had even less awareness with 74% stating that they did not know the
age range over which the law requires children to use a car seat and 86% did not know
the minimum height requirements.
 At least 6 million cars (around 25% of all cars) are fitted with standardised ISOFIX
fittings. Despite this, 74% of drivers were not aware of ISOFIX.
 Men (31%) and those who cared for children (44%) were more likely to say they knew
 Of those who said that they didn't know what ISOFIX was:
o 11% said it was a device to reduce toxic exhaust emissions
o 3% said it was a universal roof rack attachment
o 2% said it was a system to stop windscreen washers freezing up
o 2% said it was tie-down hooks in the boot to stop luggage sliding around
 36% said that they did not have the anchorage points required to attach an ISOFIX seat
 29% said they did, with 8% saying that they did and that they actually used an ISOFIX
restraint
 35% didn't know if they had ISOFIX anchorage points
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Title:
Author:
Published:
Link:
Objectives:
Methodology:
Child Restraint Use Survey: LATCH Use and Misuse
Lawrence E. Decina, Kathy H. Lococo, and Charlene T. Doyle
National Highway Traffic Safety Administration, December 2006
www.nhtsa.gov/DOT/NHTSA/Communication%20&%20Consumer%20
Information/Articles/Associated%20Files/LATCH_Report_12-2006.pdf
To collect information about the types of restraint systems being used.
In particular, to identify whether drivers with Lower Anchors and
Tethers for CHildren (LATCH)-equipped vehicles were using LATCH to
secure their child safety seats to the vehicle, and if so, were the seats
properly installed.
An observational survey of the use, misuse and consumer reaction to
LATCH at 66 sites (shopping centers, child care facilities, health care
centers, and recreation facilities) in seven States, and interviews with
the drivers on their satisfaction with LATCH and their reasons for using
or not using it.
Key Findings:
 55% of child safety seats, located in a seating position equipped with an upper
anchor, were attached to the vehicle using an upper tether.
 In 13% of the observations, the child safety seat was placed in a seat position in the
vehicle not equipped with lower anchors - the seat belt was used to secure the child
safety seat to the vehicle.
 Among the 87% who placed the child safety seat at a position equipped with lower
anchors, 60% use the lower attachments to secure the child safety seat to the
vehicle.
 81% of upper tether users and 74% of lower attachments users said upper tether
and/or lower attachments were easy to use.
 75% preferred lower attachments over seat belts of those with experience using both
lower attachments and seat belts.
 61% of upper tether nonusers and 55% of lower attachments nonusers cited their
lack of knowledge – not knowing what they were, that they were available in the
vehicle, the importance of using them, or how to properly use them - as the reason
for not using them.
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Title:
Author:
Published:
Link:
Objectives:
Proposal for a new Regulation on Child Restraints Systems
United Nations Economic Commission for Europe (UN ECE)
UN ECE 2012
http://www.unece.org/fileadmin/DAM/trans/doc/2012/wp29/ECETRANS-WP29-2012-53e.pdf
To introduce a new regulation for the design and use of child restraint
systems.
N/A
Methodology:
Key Findings:
 i-size, a new European standard for child restraints, was introduced on 9 July 2013.
 i-size will run in parallel with the existing R44.04 standard for the next few years.
 i-Size only applies to ISOFIX seats.
 i-size seats will fit every i-Size approved vehicle and cars will need to be i-Size
compliant to achieve the maximum Euro NCAP rating.
 The main changes that i-size introduces are:
o Child restraint systems will be based on the child’s height rather than weight
o i-Size rearward-facing restraints are for babies up to 15 months old
o a side impact test.
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Title
Author
Infant car safety seats and risk of head injury
Camille L. Stewart, Megan A. Moscariello, Kristine W. Hansen,
Steven L. Moulton
Published
Journal of Pediatric Surgery, Volume 49, Issue 1, January 2014
Link
http://www.ncbi.nlm.nih.gov/pubmed/24439608
Objectives
To assess whether car safety seats are inadequately protecting
infants from traumatic brain injuries.
Methodology Analysis of crash data from the Colorado State Department of
Transportation (2007–2011) and State Department of Public
Health data (2000–2011) regarding infants who presented to a
trauma center after a motor vehicle crash.
Key Findings
 Colorado Department of Transportation data found 833 under one year old
children were injured in motor vehicle crashes between 2007 and 2011, 94%
of whom (782) were properly restrained in a child car seat.
 Properly restrained infants were 12.7 times less likely to present to a trauma
center after a motor vehicle crash.
 However, the likelihood of the child passenger receiving traumatic brain
injuries in higher speed crashes was similar among properly restrained and
improperly or unrestrained infants.
 The average speed of the vehicles in which children were injured was 44.6
mph.
 Infants involved in moderate to high speed crashes often suffer significant
head injuries despite being properly restrained.
 Child car seats are effective in protecting infants, but improvements are
needed, with current impact speeds at which USA child car seats are tested
being too low.
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75
Title
Injury risk for matched front and rear seat car passengers by
injury severity and crash type: An exploratory study
Author
R.J. Mitchell , M.R. Bambach, Barbara Toson
Published
Link
Objectives
Accident Analysis and Prevention Vol 82, 2015
http://www.ncbi.nlm.nih.gov/pubmed/26087473
To examine the injury severity risk for rear seat compared to front
seat car passengers.
Methodology A retrospective matched-cohort analysis of vehicle crashes
involving injured rear vs front seat car passengers identified in
linked police-reported, hospitalisation and emergency department
(ED) presentation records during 2001–2011 in New South Wales
(NSW), Australia
Key Findings
 Of the 10,007 car passengers in 3,681 vehicles identified in this study who
were killed or injured in car crashes, 5,419 were front seat passengers and
4,588 rear seat passengers.
 There was a higher odds of sustaining a higher injury severity as a rearcompared to a front seat car passenger, with a higher odds of rear seat
passengers sustaining serious injuries compared to minimal injuries.
 Where the vehicle occupant was older, travelling in a vehicle manufactured
between 1990 and 1996 or after 1997, where the airbag deployed, and where
the vehicle was driven on a road with a speed limit of 70 km/h or more there
was a higher odds of the rear passenger sustaining a higher injury severity
then a front seated occupant.
 Rear seat car passengers are sustaining injuries of a higher severity
compared to front seat passengers travelling in the same vehicle, as well as
when travelling in newer vehicles and where the front seat occupant is
shielded by an airbag deployed in the crash.
 The increased risk of serious injury for rear seat passengers is likely to be due
to the introduction of safety features aimed at front seat protection, such as
frontal airbags.
 Rear seat occupant protective mechanisms should be examined.
 Pre-hospital trauma management policies could influence whether an
individual is transported to a hospital emergency department.
 Further examination of injury severity between rear and front seat passengers
is warranted to examine less severe non-fatal injuries by car seating position
and vehicle intrusion.
Format Pdf
Cost: Free
Keywords Injury severity; Rear seat passenger; Matched-cohort study; Road
trauma
76
Title
Author
Published
Link
Objectives
Methodology
National roadside survey of child restraint system use in
Belgium
Mathieu Roynard, Peter Silverans, Yvan Casteels, Philippe Lesire
Accident Analysis & Prevention 62, 2014
http://www.sciencedirect.com/science/article/pii/S00014575130034
61
To obtain population-based estimates of the prevalence of correct
and incorrect use of child car restraints and to identify predictors of
misuse on the basis of observations in real traffic conditions.
A roadside survey of child restraint system use and misuse
conducted on randomly selected sites across Belgium, stratified
across various types of journeys. Interviews with drivers were also
conducted. The principal parameters analysed were the
characteristics of the children and the car drivers, type of journey,
types of CRS and types of misuse.
Key Findings:
 1,461 children (under 135 cm tall) were observed travelling in cars.
 At least 50% of the children observed were not correctly restrained and 10%
were not restrained at all.
 The most significant factors associated with child car restraint use were the use
of a seatbelt by the driver, whether the CRS was bought in a was bought in a
supermarket rather than specialised shop and the age of the children.
 31% of children being driven by for unbelted drivers were not in a child car
restraint, whereas only 7% of children being driven by belted drivers were
unrestrained.
 32% of correctly restrained children were being driven by drivers who were not
wearing their seat belt, whereas 54% of correctly restrained children were being
driven by drivers who were wearing their seat belt.
 27% of child car restraints that had been bought in a specialized shop were
misused compared to 45% of child car restraints that bought in a supermarket.
 The proportion of correctly restrained children decreasing from 75% at age 0 to
24% at age 8 and then increased back up to 63% at age 10.
 Although the sample of ISOFIX users was small (n = 76), it appears that the
ISOFIX system reduced misuse significantly.
 Most of the drivers were ignorant of their own errors concerning inappropriate
and/or misuse of their child car restraint or they were remiss and underestimated
the risk.
 The three main reasons given by the drivers to explain or justify the misuse were
low attention level to safety (inattention, time pressure, and short distance), the
child’s resistance to being restrained, children restraining themselves and
problems with the restraint.
 These results suggest little or no change in the level of correct child car restraint
use over the last previous years
Format Pdf Cost: Free
Keywords: Child restraint system (CRS) CRS use CRS misuse Unrestrained
Inappropriate CRS use ISOFIX Roadside survey
77
Title
Author
Published
Link
Adopting child restraint laws to address child passenger
injuries: Experience from high income countries and new
initiatives in low and middle income countries
Lisa Keay, Julie Brown, Kate Hunter, Rebecca Ivers,
Injury, Volume 46, Issue 6, June 2015
http://www.ncbi.nlm.nih.gov/pubmed/26003092
Objectives
To describe the experience of high income countries in achieving
high levels of child car restraint use.
Methodology Editorial article
Key Findings
 Child car restraint laws are one of the five key road safety laws named in the
Global Decade of Action for Road Safety.
 While comprehensive seat belts laws cover 69% of the world’s population,
child car seat laws cover only 32%.
 Child car restraint laws are more common in high income countries but new
laws are being enacted in middle and low income countries.
 Even though child restraint laws are important, experience in high income
countries shows that high levels of compliance are difficult to achieve with
education and enforcement programmes, and support programmes to
distribute child restraints.
 As with other forms of legislation, enforcement programmes are critical to
achieving high levels of compliance.
 According to the WHO, only 17% of the 96 countries with child restraint laws
have good enforcement programmes.
 Experience in high income countries also shows that education and consumer
information programmes are needed to ensure that good quality child
restraints are provided, and that best practice in using child car restraints is
adopted.
Format: Pdf Cost: Free
Keywords
Child car restraints, child car restraint legislation, compliance, WHO
78
Title
Author
Published
Link
Objectives
Methodology
Examining the relative effectiveness of different message
framing
strategies
for
child
passenger
safety:
Recommendations for increased comprehension and
compliance
Kelli England Will, Lawrence E. Decina, , Erin L. Maple, and Amy M.
Perkins
Accident Analysis & Prevention, Volume 79, June 2015
http://www.sciencedirect.com/science/article/pii/S00014575150008
22
To evaluate various methods of framing child passenger safety
recommendations, and to examine the relative effectiveness on
parents’ knowledge, attitudes, and behavioural intentions related to
best practice and proper use of child restraints.
A randomized experiment in which 300 parents answered a presurvey, viewed one of four versions of a child passenger safety
leaflet or were in a no-education control version, and completed a
post-survey. The surveys measured child passenger safety
knowledge, attitudes, perceptions of efficacy and risk, and
behavioural intentions.
The four leaflets communicated the same child passenger safety
recommendations, but each version employed a different emphasis
frame (a persuasion technique that involves placing focus on
specific aspects of the content in order to encourage or discourage
certain interpretations of the content). The four versions were (1)
recommendations organized by the natural progression of seat
types; (2) recommendations which focused on avoiding premature
graduation; (3) recommendations which explained the riskreduction rationale behind the information given; or (4)
recommendations which were organized by age. In a fifth noeducation (control) condition, participants viewed marketing
materials.
Key Findings
 Age-appropriate child restraints and putting children in the rear seats dramatically
reduce injury in vehicle crashes. But parents and caregivers struggle to comply
with child passenger safety recommendations, and frequently make mistakes
when choosing and installing restraints.
 The risk-reduction rationale leaflet outperformed other flyers for many subscales,
and significantly differed from no-education control for the most subscales,
including restraint selection, rear seat knowledge, rear-facing knowledge and
attitudes, total efficacy, overall attitudes, and stated intentions.
 The premature graduation flyer performed best for efficacy subscales, but did not
significantly differ from the risk reduction rationale flyer for total efficacy. For
changes in self-efficacy, the premature graduation flyer outperformed all other
flyers.
 The natural progression flyer performed best for attitudes subscales, but did not
significantly differ from the risk reduction rationale flyer.
 The age-based flyer performed significantly better than control only for changes
79
in overall attitudes and stated intentions. However, the age-based flyer was
outperformed by the risk reduction rationale flyer for restraint selection score.
 All materials were rated favourably, with no significant differences among flyers
for parent’s ratings.
 This provides insight for increasing caregiver understanding and compliance with
child passenger safety information.
 Recommendations include communicating the rationale behind the information
given, using behaviour-based directives in headers, avoiding age-based headers,
and incorporating rear-seat positioning directives throughout.
 Real behavior was not observed, only behavioural intentions, which do not
always lead to actual behavior change.
Format Pdf
Cost: Free
Keywords
Transportation safety; Child restraint; Risk communication; Injury; Child passenger
safety
Title
Author
Published
Link
Objectives
Methodology
Evaluation of a child passenger safety class in increasing
parental knowledge
Valerie M. Muller, Rita V. Burke, Helen Arbogast, Perla C. Ruiz,
Nellie M. Nunez, Katherine R. San Mateo, Francesca Cazzulino,
Jeffrey S. Upperman
Accident Analysis & Prevention 63, 2014
http://www.sciencedirect.com/science/article/pii/S00014575130043
14
To evaluate the effectiveness of a car seat class in increasing
parental knowledge about child passenger safety.
Child car seat classes were held at a Level 1 pediatric trauma
center every other Tuesday for ten months. The curriculum
consisted of a child passenger safety laws discussion, a 21-min
video on the use of child safety seats followed by a 15-min
discussion about the video, 15 min of discussing the different types
of car seats, and hands-on training on how to properly install and
use child restraints. Free car seats were provided to eligible
parents. A pre-test was administered at the beginning of class and
a post-test at the end of the class.
Key Findings
 Child passenger restraint systems greatly reduce the risk of injury and death
among child passengers, but nearly half of the children who died in 2009 as a
result of motor vehicle crashes were completely unrestrained.
 Our global hypothesis is that parents and other caregivers failed to restrain
children due to a lack of child passenger seat education and practice
 In this report, we postulate that a car seat class will improve the basic
understanding of child passenger safety.
 Forty-four classes were held, attended by a total of 491 parents and caregivers.
 An increase in knowledge was found for all survey questions.
 Mean knowledge score for the post-test was 3.10 points higher compared to the
mean knowledge score from the pre-test.
80









Mean difference in knowledge scores for English-speaking participants were
higher than Spanish-speaking participants.
The results of the current study demonstrate an increase in knowledge postintervention. Similar hospital-based education and seat distribution interventions
also found an increase in knowledge post-intervention.
Previous investigators found that an educational video can increase the use and
knowledge of child passenger safety seats, however, our results demonstrated a
higher difference in mean scores (2.52 point increase) between the pre- and
post-tests.
Videos in a hospital waiting room area are a passive method of using an
educational video. Our video was shown in a class specific for child passenger
safety education, during which parents might have paid more attention to the
video.
Our video was also followed by a discussion about the video’s content, which
might have resulted in greater retention and comprehension of the video’s
messages.
Booster seat use and knowledge also increased significantly post-intervention in
this study.
Our results are consistent with similar studies, however, we believe that
incorporating additional types of interactive and hands-on teaching methods may
boost a gain in knowledge among the class participants.
This intervention was effective at increasing parental knowledge about child
passenger safety.
The results of this study may be used to design and implement future
interventions in multicultural settings
Format Pdf Cost: Free
Keywords
Child passenger safety Child restraints Intervention
81
Title
Author
Published
Link
Objectives
Methodology
Keeping baby safe: A randomized trial of a parent training
program for infant and toddler motor vehicle injury prevention
Lynne Swartz, Ann Glang, David C. Schwebel, E. Gwen
GeigerWolfe, Jeff Gau, Susan Schroeder
Accident Analysis & Prevention 60, 2013
http://www.sciencedirect.com/science/article/pii/S00014575130029
47
To evaluate “Keeping Baby Safe In and Around the Car”, a
multimedia DVD designed to improve knowledge about car seat
installation among parents of infants and toddlers.
A randomized controlled trial with 195 parents of children aged 0 –
24 months in which effective car seat use was measured via a
written knowledge quiz and car seat simulation.
Key Findings
 The treatment and control groups did not statistically differ on demographic
characteristics or baseline outcome measures, suggesting randomization created
initially similar groups.
 Post-test scores on both knowledge and car seat simulation measures for the
intervention were significantly higher than those of the control group.
 96.7% of Parents who responded to user satisfaction questions indicated that
they agreed or strongly agreed the program was helpful to them.
 98.9% recommended the program to other parents.
 In response to the open-ended program use/satisfaction questions, several
parents in the treatment group commented on the usefulness of viewing video of
correct child safety seat installation.
 Several users made recommendations for distributing the DVD to appropriate
target audiences, such as expectant and new parents.
 The results were consistent across outcome measures and regardless of child
age, suggest that viewing the “Keeping Baby Safe In and Around the Car” DVD
resulted in significant gains in parents’ car seat knowledge and their ability to
discriminate the critical elements of correct car seat installation.
 DVD programs offer a promising format for learning about child seat safety. They
can teach, demonstrate and facilitate desired behavior change by providing
parents with visual examples and context. The format also accommodates
parents’ busy schedules, time constraints, and family obligations.
 When a parent owns such a program, it becomes a resource for repeated use
and reinforcement of knowledge.
 A significant challenge disseminating effective programs to the target
populations.
 Dissemination of engaging multimedia DVDs such as this program might reduce
motor vehicle crash-related injuries to infants and toddlers.
Format Pdf Cost: Free
Keywords
Unintentional injuries Car seat safety Randomized control trial Infants Parent training
Observation study
82
Title
RANKING EU PROGRESS ON CAR OCCUPANT SAFETY, PIN
Flash Report 27
Author
Graziella Jost, Richard Allsop and Alessio Ceci, European
Transport Safety Council (ETSC)
Published
European Transport Safety Council (ETSC), April 2014
Link
http://etsc.eu/ranking-eu-progress-on-car-occupant-safety-pinflash-27/
Objectives
To assess progress on improving car occupant safety and to
make recommendations to Member States and EU institutions for
measures to further reduce death and injury to car occupants.
Methodology The ETSC Road Safety Performance Index (PIN) is a policy tool
to help EU Member States improve road safety, by comparing
their performance to identify and promote best practice in Europe
and bring about the kind of political leadership that is needed to
create a road transport system that maximises safety.
Key Findings
 Around 240,000 car occupants were killed in road collisions in the EU27
between 2001 and 2012. There were 12,345 deaths in cars in 2012
compared with 27,700 in 2001, a cut of 55%.
 Deaths of car occupants were cut by more than the overall death rate
(49%) and substantially more than the rate for other road users (41%).
 Car occupants have benefitted more than other road users over the past
decade because many road safety measures have targeted car occupants
including improved vehicle occupant protection. But car occupant deaths
still represented almost half (48%) of all road deaths in 2010-2012.
 Car occupant deaths decreased in all PIN countries since 2001. Spain and
Latvia achieved the best annual average reductions between 2001 and
2012. Good progress was also made in Switzerland, the Netherlands, the
UK and Sweden which are now the safest countries in terms of car
occupant deaths per billion vehicle-km travelled.
 Car occupant deaths as a percentage of recorded road deaths in the PIN
countries in 2012 ranged from 33% to 70%, and in most countries were
between 40% and 60%.
 4 children (aged 0 to 14) per million child population were killed in cars
across the EU each year between 2010 and 2012. This rate ranged across
most of the PIN countries from less than 1 to more than 8. Correct fitting
and use of child restraints is important in preventing such deaths.
 Key recommendations to Member States include adopting strong
legislation and apply best practice in enforcement against speeding, drink
driving and the non-use of seat belts and child restraints.
 Key recommendations to EU institutions include aligning type approval
crash tests with high performing Euro NCAP crash tests, and extending
mandatory fitment as standard equipment of an enhanced seat belt
reminder system for all vehicle seats with audible and visual warnings.
Format Pdf
Cost: Free
Keywords: Child car occupants, child restraints
83
Title
Author
Published
Link
Objectives
Methodology
Use of top tethers with forward-facing child restraints:
Observations and driver interviews
Angela H. Eichelberger, Lawrence E. Decina, Jessica S. Jermakian,
Anne T. McCartt
Journal of Safety Research, Volume 48, February 2014
http://www.sciencedirect.com/science/article/pii/S00224375130016
79
To identify why parents do not use the top tether when securing
their child car restraints.
A survey conducted primarily at shopping centers, recreation
facilities, child care facilities, car seat check events, and health care
facilities in which drivers were asked about their knowledge and use
of top tethers and experience with child restraints. Tether use was
observed to verify whether tethers were being used correctly.
Key Findings
 In the USA, LATCH (Lower Anchors and Tethers for Children) is a system for
attaching child restraints to vehicles.
 The LATCH system has lower attachments on child restraints that connect to
anchors built into the vehicle, and a top tether that attaches the child restraint
to an anchor on the rear shelf, seat back, floor, cargo area, or ceiling. The
lower attachments are designed to replace the vehicle seat belt as the primary
attachment to the vehicle, but the top tether should be used when installing a
forward-facing restraint with either the lower attachments or the vehicle seat
belt.
 479 drivers had forward-facing child restraints equipped with tether anchors in
their vehicles 56% of forward-facing child restraints were installed with the
tether; 39% were installed with the tether used correctly.
 The tether was used with 71% of LATCH lower anchor installations and 33%
of seat belt installations.
 Drivers who installed child restraints without tethers most often said they did
not know about the tether or how to use it.
 The rate of tether use in the current study was slightly higher than in previous
studies, but many parents and caregivers continue to use forward-facing child
restraints without attaching the tether.
 Tether use is particularly low with seat belt installations compared with
LATCH lower anchor installations. This finding suggests that many drivers do
not understand that the tether should be used with either type of installation.
 Parents not using tethers most often said they did not know about tethers or
did not know how to use them.
 Because the main problem is lack of awareness of the tether or how to use it,
public education should focus specifically on the safety benefits of tethers and
how to use them.
Format: Pdf Cost: Free
Keywords
LATCH; Tether use; Child restraints; Observations; Interviews
84
Title
Author
Published
Link
Objectives
Methodology
Are Parents and Carers Fitting Child Car Seats Correctly?
Mark Pitcher, TRL
TRL presentation at the Harrogate International Nursery Fair, March
2015.
http://www.trl.co.uk/media/747364/are_parents_fitting_child_car_se
ats_correctly__31-3-15_v2.pdf
To identify the level of child car seat misuse and the most commons
forms of misuse.
Analysis of 1,576 records of information collected during child car
seat checking clinics, mostly held in 2013.
Key Findings
 Since 2010, TRL has been collecting information gathered during child car seat
checking clinics conducted in over 50 locations in England and Scotland.
 Children’s age, weight and height was recorded to enable an assessment of
whether the child car seat being used was appropriate for the child.
 83% of parents/guardians were able to provide the child’s age.
 However, only 15% of parents/guardians knew their child’s weight.
 This is a particular concerned as most child car seats conform to ECE R44, and
are based on the child’s weight. Parents/guardians who do not know the weight
of their child, are more likely to put them in an inappropriate child seat.
 13% of the children observed in a forward-facing group 1 child car seat were
below the minimum weight of 9kg for that type of seat, and should have been in
a rearward-facing seat.
 No children above 9kg were in a rearward-facing child seat, even though group
0+ seats allow children to stay rearward-facing until they are 13kg in weight.

4% of the children observed exceeded the maximum weight for the Group 1
child seat they were using.
 24% of the children who were in booster seats were under the minimum weight
of 15kg for that type of seat.
 Only 2% of the parents/guardians who participated in the clinics knew their
child’s height. This is important because the new 1-size (regulation 129)
standard for child car seats is based on children’s height.
 In general, only 40% of the child car seats recorded in the database were fitted
correctly.
 60% of the child car seats recorded in the database had at least one form of
misuse, most commonly the:
o child seat’s internal harness too loose (20%)
o seat belt holding the child seat too loose (17%)
o seat belt routed through the child seat incorrectly (15%)
o child seat’s internal harness incorrectly fitted (6%)
o child seat’s internal harness twisted (3%).
 Levels of misuse of child car seats remain high and so education and checking
clinics are essential.
Format Pdf
Cost: Free
Keywords
Child car seats, child restraints, misuse, checking clinics
85
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