Child Restraints

Child Restraints

How Effective?

In 2016, 18 children under 12 years old were killed while travelling in cars in Great Britain, 247 were seriously injured and there were 5,268 child car casualties (reported to the police) in total. (RRCGB, DfT, 2017)

Child Casualties in Cars, 2016, Great Britain1

  Killed Seriously Injured All
0 - 4 years 7 83 1,521
5 - 7 years 3 73 1,603
8 - 11 years 8 91 2,144
Total* 18 247 5,268

*Includes age not reported.

Over the five year period, from 2012 to 2016, 67 children under 12 years old were killed in car crashes, 1,024 were seriously injured and there were over 25,000 child car passenger casualties in total.[1] 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.

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 rear-facing 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)

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)

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)

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)

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 Willett Willett 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 childseats 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)

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)

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 anti-submarining 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)

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 amongrestrained 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 seatedon 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)

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)

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 i-Size) 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)

  Front Seat Passengers   Rear Seat Passengers  
  1 - 4 years old 5 - 9 years old

1 - 4 years old

5 - 9 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 and cushions used:

Properly

21 28 18 37
Wrongly 0 0 0 0

Unrestrained:

On seat

5 1 1 6
On passenger's lap 1 0 1 0

 

 

 

 

 Misuse of Child Car Restraints

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)

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.

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)

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)

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)

More recent data from the EC-funded CASPER project found that misuse of child seats is still a widespread and serious problem (based on studies in Berlin, Lyon and Naples). 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.

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 mis-use problems could probably be reduced by providing better help and guidance top parents. (Lesire et al, 2013a)

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. This study 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)

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)

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)

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)

ISOFIX

ISOFIX is a system for the connection of child restraint systems to vehicles. It has two rigid anchorages built into the vehicle and 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)

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 non-LATCH-equipped ones. (Decina, 2006)

i-size

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, 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 ISOFOX Child Restraint Systems) is a category of child restraints that are for use in all seating positions in a motor vehicle that are designated as i-Size seating positions by the vehicle manufacturer. The system is intended to be ‘plug and play’ in order to simplify the fitting of child restraints.

i-Size seats must be marked with the i-Size logo.

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)

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. Education-only 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.

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 centre, 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)

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)

 

 

References

1 See https://www.gov.uk/child-car-seats-the-rules for details of the law about child car restraints in Great Britain.

  • Date Added: 03 Apr 2012, 08:16 AM
  • Last Update: 11 Dec 2017, 04:25 PM