Safety and Injury Prevention

Auto Safety

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Starting with a baby's very first journey home from the hospital, parents are responsible for ensuring their child's safety during travel. Unintentional injury is the leading cause of death in children and more kids are killed in automobile crashes than in any other type of unintentional injury.

You can protect your kids by following simple safety measures and by teaching some basic rules.

Importance of Child Safety Seats

Using a child safety seat (car seat) is the best protection you can give your child when traveling by car. Every state in the United States requires that an infant or small child be restrained — and with good reason. Child safety seats can reduce the risk of a potentially fatal injury substantially for babies in particular and also for toddlers. But many safety seats are used incorrectly.

When choosing any car seat, following some general guidelines will help ensure your child's safety. The best car seat is not always the most expensive one — it's the one that best fits a child's weight, size, and age, as well as your vehicle.

Once you select a seat, be sure to try it out, keeping in mind that store displays and illustrations might not show the correct usage. It's up to you to learn how to install a car safety seat properly and harness your child for the ride.

If you need help installing your safety seat or would like a technician to check whether you've installed it properly, the federal government has set up child seat inspection stations across the country.

Also, many local health departments, public safety groups, hospitals, law enforcement agencies, and fire departments have technicians or fitting stations to assist parents. (If you go to one of these locations, be sure to ask for a certified child child passenger safety technician to assist you.)

Guidelines for Choosing a Safety Seat

  • Choose a seat with a label that states that it meets or exceeds Federal Motor Vehicle Safety Standard 213.
  • Accept a used seat with caution. Never use a seat that's more than 6 years old or one that was in a crash (even if it looks OK, it could be structurally unsound). Avoid seats that are missing parts, are not labeled with the manufacture date and model number (you'll have no way to know about recalls), or do not come with an instruction manual. If you have any doubts about a seat's history, or if it is cracked or shows signs of wear and tear, don't use it.
  • If you accept a used seat, call the manufacturer to find out how long they recommend using the seat and if it was ever recalled. Recalls are quite common, and the manufacturer may be able to provide you with a replacement part or new model.

Infant-Only Seats (Birth to 22-35 Pounds)

Infant-only seats fit newborns and smaller infants best, but you will have to buy another seat as your baby outgrows it. Infant-only seats are designed to protect babies from birth until they reach up to 35 pounds (about 16 kilograms), depending on the model.

Infant car seats should always be installed to face the rear of the car because in a crash the back of the safety seat cradles the baby's head, neck, and torso. The American Academy of Pediatrics (AAP) recommends that infants and toddlers ride in a rear-facing seat until they are 2 years old or until they have reached the maximum weight and height limits recommended by the manufacturer.

Many parents have been turning the safety seat around to face the front when their child reaches a weight of 20 pounds (9 kilograms) or 12 months of age, as previous recommendations gave that age and weight as a minimum for front-facing car seats.

Yet recent studies show that a child under age 2 is 75% less likely to die or incur a serious injury when in a rear-facing seat. That's because at this age, a child's neck usually isn't strong enough to support the head in the event of a crash.

So it's essential to follow the height and weight guidelines on the child safety seat and keep your child in a seat that faces the rear as long as it's possible and the seat still fits.

Infant-only safety seats are convenient because they're designed to double as carriers, chairs, or rockers when not used in the car. Many models detach right from the base, allowing you to leave the base installed in the car.

Try to limit the amount of time your infant spends in the car seat while you're at home or while the baby is at childcare. Too much time in a car seat can limit a baby's movement and opportunities for stimulation, which are important for developing sensory and motor skills.

How to Install an Infant-Only Seat

Prior to installing your baby's infant-only seat, read the product manual thoroughly. These tips can help with the installation:

  • An infant-only seat should be placed in the back seat, ideally in the middle of the back seat, but most important, in a position where it fits securely.
  • Read the owner's manual for your vehicle to find out how to use its seatbelts with a child safety seat.
  • Use your knee to push down on the seat as you tighten the car's seatbelt through the belt path. The car seat should not move more than 1 inch (3 centimeters) from side to side or forward and backward at the belt path. If the seat wiggles or moves on the belt path, the belt needs to be tighter.
  • Some seatbelts may require a special locking clip designed specifically to keep the belt from loosening. Locking clips are available from baby product stores, safety seat manufacturers, and some car dealerships.
  • Be sure to check the tightness of the safety seat before each use.
  • Never use an infant-only seat in a forward-facing position.
  • The car seat should recline at no more than a 45-degree angle.

How to harness your infant:

  • Read the entire child safety seat manual.
  • Your baby's head should be at least 2 inches (6 centimeters) below the top of the safety seat.
  • Infant-only seats are usually designed with a 3-point or 5-point harness. The harness should always be placed in the slots and should always be at or below your baby's shoulders. Most models have a chest clip that holds the harness straps together. Move the clip so the top of it is level with your baby's armpits.
  • All harness straps should fit snugly, especially over the shoulder and thigh areas. Straps should always lie flat, never twisted. If you can pinch any harness webbing between your fingers, it's too loose.
  • Dress your baby in clothes that keep his or her legs free. This will allow you to buckle the latch crotch strap properly between the legs. If it's cold outside, harness your baby first and then cover him or her with a blanket (never cover your baby's head). Never buckle a blanket under or behind the baby.
  • If your baby slouches to one side in the seat (common among newborns), place rolled-up cloth diapers or rolled hand towels on each side of the shoulders. There are supports specially designed for car seats, but only use them if they came manufactured with your safety seat. Never place any kind of padding or blanket under your baby — this can affect the harness's ability to restrain your little one.
  • If your baby's head flops forward (also common with newborns), check the angle of the seat. Use a towel or blanket to tilt the seat back slightly (a 30- to 45-degree angle is best).

Convertible Seats (Birth to 40 Pounds)

Convertible seats are designed to protect kids from birth up to at least 40 pounds (18 kilograms) facing backward, and up to 65 pounds (30 kilograms) or even 80 pounds (36 kilograms) facing forward, depending on the model.

Convertible seats are the only type of seats that are placed in different positions depending on a child's age: They face toward the rear until a baby is ready to face forward, when they can be turned around and "converted" to a forward-facing seat.

Weight ranges vary on convertible car seats, so it is important to consider a child's height and weight before buying one. Convertible seats are heavy and not very portable. Yet they can be economical because it may not be necessary to buy a separate infant-only seat. It's also a good option for larger babies who outgrow their infant-only seat and still need to be rear facing.

If using a convertible seat, make sure it fits your child correctly — a small child in a large seat may not be the best option. Models with tray shields should not be used for newborns — the shield comes up too high on them, and in a crash the baby's face could hit the tray.

How to Install a Convertible Seat

  • An infant or small toddler should be placed in the back seat — preferably in the middle — and must be facing toward the rear of the vehicle until 2 years of age or until reaching the maximum weight and height limits recommended by the seat's manufacturer.

    A child who reaches the height and weight limits before age 2 is safest in a bigger convertible seat and kept rear facing. Kids who are small can remain in rear-facing seats even after age 2. (Follow the manufacturer's guidelines for when to turn the seat.)
  • After your child has reached at least 20 pounds (9 kilograms) and at least 1 year of age, the seat may be turned to face forward, but it's wise to keep your child rear facing for as long as possible. (Follow the manufacturer's guidelines for when to turn the seat.)
  • Read the owner's manual for your vehicle to find out how to use your car's seatbelts or LATCH (Lower Anchors and Tethers for Children) system with a child safety seat.
  • Read the entire child safety seat manual. Be sure to check the recommended angle of recline for the seat when it is forward facing and rear facing.
  • Use your knee to push down on the seat as you tighten the car's seatbelt (lap-only or lap/shoulder) or LATCH attachment belt through the child safety seat's belt path. The seat should not move more than 1 inch (3 centimeters) side to side or forward and backward on the belt path. If the seat wiggles or moves on the belt path, the belt needs to be tighter.
  • Some seatbelts may require a special locking clip designed specifically to keep the belt from loosening. Locking clips are available from baby product stores, safety seat manufacturers, and some car dealerships.
  • Be sure to check the tightness of the safety seat before each use.

Harnessing infants and toddlers:

  • Read the entire child safety seat manual.
  • Shoulder straps should be threaded through the lowest harness slots to best protect your baby. They should be at or below your baby's shoulders.
  • Convertible seats usually have one of three harness options: the 5-point harness, the tray shield, and the T-shield. The 5-point harness offers the best protection for infants because it can tighten to fit snugly and does not obstruct the baby's head. Both of the other harness options can cover a baby's face and are not recommended for infants under 20 pounds (10 kilograms) or younger than 1 year old.
  • All straps should fit snugly, especially over the shoulder and thigh areas. Straps should always lie flat, never twisted. If you can pinch any harness webbing between your fingers, it's too loose.
  • Dress your baby in clothes that keep the legs free. This will allow you to buckle the latch crotch strap properly between the baby's legs. If it is cold outside, harness your baby first and then cover him or her with a blanket (but never cover your baby's head). Never buckle a blanket under the seat straps.
  • If your baby slouches to one side or the other in the seat (common among newborns), place rolled-up cloth diapers or rolled hand towels on each side of the shoulders. There are supports specially designed for car seats, but only use them if they came manufactured with your safety seat. Never place any kind of padding or blanket under your baby — this can affect the harness's ability to restrain your little one.
  • If your baby's head flops forward (also common with newborns), check the angle of the seat. Use a towel or blanket to tilt the seat back slightly (a 30- to 45-degree angle is best).
  • Be sure to readjust harness straps as your child grows. Heavy clothing (such as a puffy winter coat) should always be placed over your child after being harnessed in the seat. (A tip: After your child is harnessed in the seat, slip his or her coat on backward for warmth.)

Forward-Facing Only Seats (20-80 pounds)

Forward-facing car seats are designed to protect children from 20 to 80 pounds (about 10 to 36 kilograms) or more, depending on the model.

All kids 2 years or older, or those younger than 2 years who have outgrown the rear-facing height or weight limit for their car seat, should use a forward-facing car seat with a full harness for as long as possible. They should only switch to a booster seat that relies on the car's adult seatbelts when they exceed the height and weight limit for their forward-facing car seat.

Combination car seats are also available that allow you to remove the harness to switch from forward-facing child safety seat to belt-positioning booster seat. Review the forward-facing convertible seat for toddlers information mentioned earlier in this article regarding proper installation of forward-facing car seats and harnessing your child.

Built-in or integrated car seats can be found in some vehicles. As with other forward-facing car safety seats, built-in seats are for kids 2 years of age and older. Some convert to belt-positioning booster seats. Weight and height limits will vary so be sure to check your owner's manual.

Booster Seats

Booster seats are vehicle safety seats for kids who have outgrown forward-facing or convertible car seats but are still too small to be properly restrained by a vehicle's seatbelts.

Many states have laws requiring booster seats for kids up to 8 years old and 80 pounds (36 kilograms), or 4 feet 9 inches (about 150 centimeters) tall. The AAP states that kids should use a booster seat until the car's lap-and-shoulder belt fits properly, which is typically when they've reached 4 feet 9 inches in height and are between 8 and 12 years old.

Guidelines for Choosing a Booster Seat

  • Choose a seat with a label that states that it meets or exceeds Federal Motor Vehicle Safety Standard 213.
  • Accept a used seat with caution. Never use a seat that's more than 6 years old or one that was in a crash (even if it looks OK, it could be structurally unsound). Avoid seats that are missing parts or are not labeled with the manufacture date and model number (you'll have no way to know about recalls), or do not come with an instruction manual. If you have any doubts about a seat's history, or if it is cracked or shows signs of wear and tear, don't use it.
  • If you accept a used seat, contact the manufacturer for recommendations on how long the seat can safely be used and to find out if it's ever been recalled. Recalls are quite common, and the manufacturer might be able to provide you with a replacement part or new model.

Types of Booster Seats

Booster seats come in many styles. Belt-positioning boosters raise kids to a height where they can safely use the car's lap and shoulder belts. They come in high-back or backless models: High-back boosters are recommended when the car has low seat backs, and backless boosters may be used if a child's head is supported up to the top of his or her ears by the vehicle's back seat or head support.

Combination seats can be used with harnesses as forward-facing safety seats or as belt-positioning booster seats when harnesses are removed. Height and weight limits for different combination seats may vary, so it's best to check the owner's manual for guidance.

Shield boosters (with no back and a shield tray in front of the child) were originally designed for cars with lap-only belts, but they do not provide adequate upper-body protection and therefore are no longer recommended.

If your car doesn't have shoulder belts in the back seat, consider having them installed by the dealer. If that's not possible, the AAP recommends keeping kids in a convertible or forward-facing seat with a full harness until an appropriate booster seat can be obtained.

How to Install a Booster Seat

  • Prior to installing booster seat, read the product manual thoroughly.
  • Booster seats should be placed forward-facing in the back seat, ideally in the middle of the back seat where there is a lap and shoulder belt.
  • Read the owner's manual for your car to find out how to use your car's seatbelts with a safety seat.
  • Be sure to check the positioning of the safety seat before each use.

How to secure your child's seatbelt:

  • Read the entire booster seat manual.
  • Make sure the lap belt is low and tight across your child's hips.
  • The shoulder belt should lay flat and snug across a child's shoulder, staying clear of the neck and face.
  • Shoulder and lap belts should always lie flat, never twisted.

Kids this age can begin to understand the importance of buckling up and may want to buckle themselves in. Be sure to check their seatbelts and offer praise when they voluntarily put them on.

When Kids Outgrow Booster Seats

Kids can stop using a booster seat when they're big enough to use the vehicle's lap and shoulder belts while sitting with their back against the vehicle's seat back with their knees bent over the edge of the seat without slouching. The lap belt should rest low, on top of the thighs, and the shoulder belt should lie comfortably across the middle of the chest.

Kids should be able to remain in this position throughout the entire trip. This usually happens when a child reaches a height of 4 feet 9 inches (about 150 centimeters) and is between 8 and 12 years old.

Remember, the shoulder strap of the seatbelt should never be fastened behind a child's back or under his or her arm. And you should never buckle two kids (or an adult and a child) under one seatbelt — a crash could cause their heads to collide.

If you frequently carpool or have other kids in your car, it's wise to have an extra booster seat handy, especially if you're unsure about whether a child meets the height requirements. It's always better to be safe than to let a child who isn't tall enough ride with just a seatbelt.

Air Bags and Kids

When combined with safety belts, air bags protect adults and teens from injury during a collision. They have saved lives and prevented many serious injuries. But young children can be injured or even killed if they are riding in the front passenger seat when an air bag opens.

Air bags were designed with adults in mind: They must open with great force (up to 200 miles per hour) to protect an average-sized, 165-pound (75-kilogram) male from injury. While this force is appropriate for adults and bigger kids, it can be dangerous for small kids, possibly resulting in head and neck injuries.

Protect kids from air-bag injury by following these rules:

  • Booster seats should be placed in the back seat. If you have no choice and must place it in the front (that is, if your car is a two-seater), push the passenger seat as far back as it will go.
  • A law passed in 1995 allows car manufacturers to install a manual cut-off switch that temporarily disables a passenger-side air bag. As recommended by National Highway Traffic Safety Administration, if you must place a child in a booster seat in the front seat and your car has this cut-off switch, disable the air bag for the duration of the ride. Be sure to switch the air bag back on when you remove the booster seat.
  • All kids under 13 years of age should always ride in the back seat, and in the middle of the back seat whenever possible. All passengers must have their seatbelts buckled.

The LATCH System

Since September 2002, most new vehicles have safety seat anchorage points and most safety seats have anchor attachments.

One of the problems with installing safety seats properly has been incompatibility between the car seat and the vehicle. The Lower Anchors and Tethers for Children (LATCH) system was devised to make installation easier because it does not require use of the car's seatbelts.

Instead, a tether strap secures the top of the safety seat to an anchorage point either on the rear shelf area, the rear floor, or the back of the rear seat of the car, depending on the vehicle model. Lower anchors secure attachments on the bottom of the safety seat to a point located between the car's seat cushion and seat back.

You should use LATCH only in seating positions recommended by both the vehicle manufacturer and the car seat manufacturer. Never use both the seatbelt and LATCH to install a car seat. Choose whichever method secures the car seat best.

Most forward-facing safety seats made after September 1999 are equipped with top tether straps, and most vehicles made after September 2000 have tether anchors. Since September 2002, most new vehicles also have lower safety seat anchorage points and most safety seats have lower anchor attachments.

If your vehicle or safety seat was purchased after these dates and didn't come with tethers or anchors, call the manufacturer.

Rules for the Car and School Bus

Most kids spend time in a car or on a school bus every day, and should be taught simple rules for traveling in them to help ensure their safety.

Be sure to explain to your kids that these rules must be followed every time, no matter who is driving or how short the ride may be.

Rules for the Car

  • A seatbelt must be worn during every car trip. It should be fastened before the car is even in motion and should be left on until the end of the trip.
  • Use all seatbelts. Most cars have lap and shoulder belts that buckle as a unit, but some have two separate belts, one lap and one shoulder. Some have a lap belt only. Teach your kids to look for and secure every belt. Also teach them not to tuck the belt under their armpit, even if they think it is more comfortable that way.
  • Never share seatbelts. It might seem like fun, but two kids should never buckle up as a pair.
  • Sit in the back seat. Kids under 13 years of age should always ride in the back seat. This protects them from possible injury when a passenger-side air bag deploys. Explain that air bags could seriously hurt a small child because they are designed to protect a person with a much bigger body.
  • Play it cool. Kids should understand the importance of staying calm and low-key in the back seat. If they are jumping around or yelling, it can distract the driver and put all the passengers at risk.
  • Follow the rules in every car. Kids need to follow the rules if they are in a friend's or relative's car, even if other passengers don't follow the rules. If asked to sit in the front seat of someone else's car, your child should politely decline the offer and tell the driver that he or she would prefer to sit in the back seat.

Rules for the Bus

  • Wait for the bus away from the street. Kids should get in a line that starts about 6 feet (2 meters) from the curb and goes away from the street rather than down the side.
  • Wait for the OK. Kids must wait until the bus driver opens the door and says that it's OK to step on. They should not step into the road even a moment sooner.
  • Be careful getting on the bus. This is especially important for older kids who may carry bags and backpacks that can get caught in a door or around a seat.
  • Wear seatbelts if possible. Some school buses are outfitted with seatbelts. They should be buckled before the bus leaves and left on until the bus arrives at its destination.
  • Play it cool. Make sure kids understand the importance of staying in their seats while the bus is moving. Running or climbing around the bus can distract the driver and be dangerous to other kids.
  • Be careful getting off the bus. When exiting the bus, kids should hold onto the handrail and step down slowly. Once off the bus, they must walk in front of it, never behind it.
  • Stay in front. When they walk in front of the bus, kids should walk on the sidewalk next to the bus for at least 10 feet (about 3 meters), make sure the bus driver acknowledges them, and then cross the street.
  • Don't disappear. A child who drops something while crossing in front of a bus should never bend over to pick it up. This makes the child invisible to the driver. Instead, teach kids to tell the bus driver if they drop something.

Reviewed by: Elana Pearl Ben-Joseph, MD
Date reviewed: April 2011



Kids Health

Note: All information is for educational purposes only. For specific medical advice, diagnoses and treatment, consult your doctor.

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