CAR SEAT SAFETY – An Emergency Physician’s Perspective


Driving in cars has become such an everyday convenience, that we often forget that even the shortest ride can be dangerous. Motor vehicle accidents remain the leading cause of death in children in the United States. Although seat belt laws and public safety campaigns in the last decade have reduced motor vehicle-related deaths, crashes still cause 1 of every 4 unintentional injury deaths. Car seats (when installed properly) reduce this risk of fatal injury in infants and children by up to 71%, when compared with a seat belt alone. And knowing how to safely and properly restrain your children can actually save their lives.

  1. Children are not “little adults.”

The unique anatomical characteristics of a child, predispose them to suffer injuries when placed into seatbelts designed to restrain an adult. For example, children typically have:

  • A smaller body size.
  • Larger and heavier heads, compared to their body length.
  • Thinner/weaker abdominal wall, and minimal abdominal wall fat, creating less protection of their inner organs.
  • A less developed spine, and one that is more flexible/susceptible to hyperextension.

These distinct physical differences create a higher center of gravity (making them “top-heavy”) and expose a larger body surface area to injury. When children experience increased deceleration forces during a crash, they are at greater risk of injuring their brain, spine, neck, large vital blood vessels, and inner abdominal organs, when compared to an adult.

This is why the National Highway Traffic Safety Administration (NHTSA), the American Academy of Pediatrics (AAP), and the Center for Disease Control (CDC) and other committees, all stress the importance of safety seats in children to reduce these potential injuries.

  1. Current guidelines (as of today).

With new data and advancing technology, the laws for child seat safety are continually being modified, and it’s important to stay abreast of the latest recommendations. The NHTSA and the AAP both currently advise:

  • Infants – toddlers (age 0-2 years) be placed in a Rear Facing Car Seat only.   
    • 5-point harness is best, and car seats are best placed in the back row, ideally in the middle seat. Young children should remain in this until they reach the upper weight/height limit for that seat.
  • Preschool Aged kids (age 2 – 5 years) should be placed in Forward Facing Car Seats
    • 5-point harness is still ideal to distribute force of impact, and children should remain in this forward facing seat until age 5, unless they reach the upper weight/height limit sooner.


  • School Aged Kids (age 5 – 8 years): This particular age-group of kids poses the biggest challenge for adequate restraint. Having outgrown their 5-point restraint car seat, these children are often prematurely advanced to a seat belt that was made for adults. In a crash, a child can slip out of the shoulder belt or “jack-knife” over the lap belt, making them particularly susceptible to terrible injury. Once your child has outgrown their forward-facing seat, school-age children should be buckled in a booster seat in the back seat of the car, until they they are at least 57 inches. The lap belt should be adjusted so that it lies snugly across your child’s upper thighs, and the shoulder belt rests across their chest (not across their neck).


  • Older Kids (taller than >57 inches) no longer need to use a booster seat once the seat belt fits them properly. However, as young tweens, the lap belt should lay across the upper thighs (not the stomach) and the shoulder belt across the chest and shoulder (not the neck). The back seat is still the safest place in the car for older kids, and children should not sit in the front seat until they are at least 13 years of age.


  • Teen drivers: Motor vehicle crashes are the leading cause of death for U.S. teens. Every day, 6 teens between 16-19 years old, die from motor vehicle injuries. Fortunately, proven strategies can improve the safety of young drivers. Remind your teens to use a seatbelt every time, regardless of how short the drive. Studies have shown that up to 56% of teens were not wearing a seatbelt at the time of a crash. And be sure to limit the number of friends in the car and help them avoid other distractions, such as cell phones. Graduated Driver Licensing (GDL) Programs have also proven to reduce injury crashes, by providing longer practice periods and limiting driving under high-risk conditions. Driving is a complex skill, and still requires much practice for teens to master.
  1. Get in the back!

Airbags have proven to save lives, however, direct impact by a deployed airbag can cause serious injury, and even death in young children. It is for this reason, that all children under the age of 13 years should be seated in the back seat. Rear-facing car seats should also never be placed in the front seat. The safest spot in a car is the middle seat of the back row, so buckle children here first.

  1. Rare exception: say “NO” to multitasking.

As parents, we often feel the need to check more items off our “to do” list, and have unwittingly become masters of multitasking. Just having children in the car can divert a parent’s attention from the road, however, driving while distracted is a deadly combination. As a driver, it is definitely time to avoid:

  • Texting
  • Reading/Facebooking/Tweeting
  • Eating
  • Pumping
  • Driving under the influence of ANY alcohol or sedating/driving-impairing drug (prescription or otherwise)
  • Pokemon Go (seriously)

Our children are our most precious cargo. Your lunch, pumping session, or text convo can wait. It’s just not worth it.

As emergency physicians, we have the unique perspective of being on the receiving end of patients brought in with serious injuries (often, fatal) due to motor vehicle crashes. It is a vivid reminder for us to slow down and take a few extra seconds to ensure that our children are restrained properly. As parents, we all need to set a good example and buckle-up as well, regardless of how short the drive, and drive without distraction. Hindsight is always 20/20, so be sure to optimize the safety of you and your children before you start the car, and arrive at all of your destinations safely.


  4. Durbin DR; Committee on Injury, Violence, and Poison Prevention.Child passenger safety.Pediatrics. 2011 Apr;127(4):e1050-66. doi: 10.1542/peds.2011-0215. Epub 2011 Mar 21.
  5. National Center for Injury Prevention and Control. 2015. Web-based Injury Statistics Query and Reporting System (WISQARS), 2014 fatal injury data. Atlanta, GA: Centers for Disease Control and Prevention.

LOGO photo with Hyperlink

by 3MD | THREE MOMMY DOCTORS™, three board-certified emergency physicians.

Treating your kids like we treat our own.™

The information contained on this post is not intended nor implied to be a substitute for professional medical advice. It is designed to support, not replace, the relationship that exists between a patient and his/her physician. For specific medical advice, diagnoses, and treatment, consult your doctor.


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  • Karen says:

    The AAP recommends that all infants ride rear-facing starting with their first ride home from the hospital. All infants and toddlers should ride in a rear-facing seat until they are at least 2 years of age or, preferably until they reach the highest weight or height allowed by their car seat manufacturer.