School Age Children Need Booster Seats to Ride Safely

The National Highway Traffic Safety Administration reports that traffic crashes are the leading cause of death for children of every age from 6 to 14 years - a fact that can be linked, at least in part, to the reality that most kids are unbuckled or improperly restrained in vehicles. One of the most common mistakes parents make when restraining children is that they don't understand the different stages of child restraint use throughout a child's growth.

Since many state laws only require child safety seat use up to age three, many parents assume older kids are safe in just a seat belt. But when children out-grow forward-facing convertible seats, they need to be restrained in belt-positioning booster seats until they are big enough to fit properly in an adult seat belt. Children who cannot sit with their backs straight against the vehicle seat back cushion, with knees bent over a vehicle's seat edge without slouching, are not big enough for adult seat belts.

Even the most safety-conscious parents are often not aware of the need for booster seats or the danger their children face when improperly restrained in an adult seat belt. On a small child, the adult lap belt rides up over the stomach and the shoulder belt cuts across the neck. In a crash, this could cause serious or even fatal injuries.

The statistics are startling. Restraint use for children from birth to age one is 97%, and ages one to four, 91%. From age five to 15, restraint use plummets over 20 points to 68.7%. According to 1998 FARS data, over 47% of fatally injured children ages four to seven are completely unrestrained. And one NHTSA study showed that only 6.1% of booster-aged children were restrained in a booster seat.

A recent study by Ann Ramsey and colleagues at the University of Washington reported in the August 2000 issue of the journal Pediatrics found that only 28% of the 149 4 to 8 year old children they surveyed were delivered to school or daycare in booster seats, and only 10% of the 6 to 8 year old children. Twenty eight percent of the 4 year olds, and 70% of the 6 to 8 year olds were wearing shoulder seat belts.

The most common reason for nonuse of booster seats for children in these age groups was parents' lack of knowledge about the inappropriateness of shoulder seat belts for children in the 40 to 80 lb. range. Most of the parents interviewed thought that their children were large enough to wear the regular shoulder seat belts.

Children generally outgrow convertible child safety seats when they are about 40 lbs. From 40 to about 80 lbs. and about 4'9" tall, children should be seated in a belt-positioning booster; lifting them so adult lap/shoulder seat belts are positioned correctly and safely. When a child's shoulders are above the top set of strap slots, it is time for a booster seat. Booster seats protect the child's upper body with either the shoulder belt or with a shield. The booster raises the child so the vehicle lap/shoulder belt fits well. Booster seats offer children better visibility and comfort.

Boosters without shields, for use only with the vehicle lap/shoulder belt. Because raising the child improves belt fit, these are called "belt-positioning boosters." Some have a high back that gives head support for taller children. Some boosters of this type are built into vehicle seats.

Boosters with removable shields. Use without the shield to make lap and shoulder belts fit right. Shield boosters are not currently approved for children weighing over 40 pounds. A child who has outgrown their convertible seat, yet weighs less than 40 pounds can be moved into a high-back booster with a harness. Once the child reaches 40 pounds, the harness is removed and the seat is used with the adult lap and shoulder belt as a belt-positioning booster.

High-backed boosters, used as belt-positioning boosters. Most have a clip or strap to hold the shoulder belt in place. Some high-backed boosters have removable harnesses. This type can be used with the harness for a child under 40 lbs. Children who reach 40 pounds before age 3 may not be mature enough to stay seated properly in a belt-positioning booster. A vest that uses the belt system and a tether strap would be an option in this situation.

Which booster is best?
The belt-positioning booster and is the best choice if your car has combination lap/shoulder belts in the rear seat. Use a booster with a high back if there is no head restraint for the child. The booster with a high back and a removable harness provides the most options in many vehicles. Check the label for the weight limit on the harness.

How long should the booster be used?
Try the vehicle belts on your child as he or she grows taller. When the child sits comfortably without slouching, with the lap belt low on the hips and the shoulder belt across the shoulder, use the belts without the booster. Lap belt fit is most important. A child is usually ready for the adult lap and shoulder belt when the child can sit with their back against the vehicle seat back cushion with knees bent over the vehicle seat edge with feet on the floor. Do your child's ears come above the top of the vehicle seat back? If so, a high-back booster will improve neck protection. Always follow manufacturer instructions.

How should a lap belt fit?
The lap belt should fit low over a child's upper thighs. Make sure the child sits straight against the seat back. Keep the belt snug. If the lap belt rides up onto the tummy, it could cause serious injuries in a crash.

How can you make a shoulder belt fit better?
The shoulder belt should stay on the shoulder and be close to the child's chest. If you have the kind of shoulder belt that stays loose when it is pulled out, make sure there is no more than one inch of slack. Too much slack will prevent the belt from working well. Teach your child to tug at the shoulder belt to take up excess slack. If the shoulder belt fits so poorly that it goes across the neck or face, raise the child with a belt-positioning booster.

NEVER put a shoulder belt under the child's arm or behind the back. Either of these kinds of misuse could cause serious injury in a crash. Some devices advertised to improve belt fit for older children and adults are not covered by government standards. They may help with shoulder belt comfort but may put too much slack in the shoulder belt or cause the lap belt to ride up. Boosters are a better solution for children who fit in them.

National Highway Traffic Safety Administration Rules to Remember:

• The safest place for any child 12 years old and under is in the back seat in a safety seat or seat belt.
• Older kids over 40 pounds should ride in a booster seat until the car's lap and shoulder belts fit right.
• The lap belt must fit low and snug on their hips. The shoulder belt must not cross their face or neck.
• Never put the shoulder belt behind their back or under their arm.
• Child seat compatibility: Not all child seats can be installed in all vehicles and all seating positions. With numerous models of child seats, almost 300 models of passenger vehicles, and the wide range of belt systems available today, correctly installing a child seat can be challenging. The best way to be sure your child seat is compatible with the vehicle you are considering is to test it before you purchase or lease the vehicle.
• Read the child seat's instruction manual and review all information in the vehicle owner's manual concerning correct installation. Once the seat is installed, check it by firmly pulling the base of the child seat from side to side and forward. The child seat should not move more than one inch in any direction.
• Have child safety seats inspected by a certified child safety seat technician in their community.

Resources for information on how to purchase and install booster seats in your vehicle, and where to find a seat inspector in you community can be found on the National National Highway Traffic Safety Administration web site or by calling 1-800-424-9393.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.