Editorials

Ensuring the safety of school age passengers

Booster seats are necessary for optimal protection

Papers p 1123

The article by Halman et al (p 1123) in this issue indicates that children of school age involved in motor vehicle crashes were less severely injured if they were wearing a seat belt, irrespective of the type of restraint or seating position in the motor vehicle.¹ The authors report that school age children (4-14 years old) restrained with a seat belt were 2-10 times as safe as unbelted children and were at least as well protected as adults wearing seat belts. The findings, however, do not answer the question about whether the degree of protection afforded children by standard seat belts is sufficient, according to the authors' discussion of the limitations of the data. The national safe kids campaign in the United States and the child passenger safety community recommend that children be protected in an appropriate child restraint or booster seat rather than in a safety belt at least up tothe age of 8 years. Premature graduation to a safety belt from a forward facing child safety seat is potentially dangerous.

Booster seats lift a child up and make the adult safety belt fit correctly. These seats position the lap belt low over the upper thigh (not riding on the abdomen) and the shoulder belt snug across the center of the shoulder (not crossing the neck or face). They also allow a child to sit back against the vehicle seat with knees bent comfortably, ensuring that correct positioning of the belt is maintained. Booster seatseither with a high back when the vehicle does not provide head support, or backlessare recommended as a transition from child restraints with harnesses (usually limited to 40 pounds or 18 kg) to the time that adult belts fit properly (around the age of 8 years). Adult safety belts fit children properly only when their knees bend over the seat while they sit as far back as possible without slouching; the shoulder belt fits snugly across the chest and the centre of the shoulder; and the lap belt fits low across the upper thighs.

Failure to use a booster seat in a crash can result in seat belt syndrome, a pattern of intra-abdominal and spinal injuries caused by the improper fit of seat belts.² Recent data from the crash injury research and engineering network indicate that children inappropriately restrained in a seat belt are nearly three and a half times as likely to suffer a severe injury than their peers appropriately restrained in a booster seat.³ Broken jaws and noses are among other less severe, but usually disfiguring, consequences of premature use of safety belts among children of school age.

Use of booster seats among children aged 4-8 has increased in recent years, especially among the youngest children. Among 4 year olds, use of booster seats increased from 14% in 1998 to 34% in 2000.⁴ Yet placing children in the correct seat for their age and size continues to be a challenge. According to an observational interactive study of over 9300 children in nearly 6300 cars, more than 63% of children who should have been in belt positioning booster seats were inappropriately restrained, most often in adult safety belts.⁵

Although it is true that safety belts are better than no restraint at all, parents should be encouraged to provide the optimal level of protection for their children of school age. The strategy for improving the use of booster seats is multifaceted and well understood by safety advocates in the United States and other nations.

One highly effective measure is to close gaps in existing laws for the protection of child occupants. In 2001 the national safe kids campaign analysed such laws throughout the United States and rated them woefully lacking.⁶ Since then, at least 10 states have improved their laws protecting child occupants in some fashion, and an additional 23 states have introduced improvement bills,lthough only six of these specifically legislate booster seats; all aim to close gaps requiring restraints for older, "forgotten," children.

Other recommended techniques include informing parents better about the importance of correct and consistent use of booster seats, continuing targeted outreach to populations at risk by using culturally appropriate messages and materials, and supporting more distribution programmes for booster seats in communities in need. Working together, society can make the use of booster seats normative so that future researchers into the safety of child passengers won't be compelled to eliminate from data analysis the "fewer than 1% of the sample" who had used a booster seat.¹

Angela D Mickalide, programme director. 

(amickalide{at}safekids.org)

Karen DiCapua, director, child passenger safety. 
Heather Paul, executive director. 

National Safe Kids Campaign, 1301 Pennsylvania Avenue, NW, Washington DC, USA