Key Points for Practice
• Infants and toddlers should ride in a rear-facing car safety seat until they reach the highest weight or height allowed by the car seat manufacturer.
• Children who have outgrown the rear-facing weight or height limit for their car seat should use a forward-facing seat with a harness as long as possible.
• When the children have outgrown the forward-facing seat limits for the car seat, they should use a booster seat until the lap and shoulder parts of the seat belt fit correctly.
• All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
From the AFP Editors
Child safety seats reduce the risk of injury and death when compared with seat belts. There has been an increase in scientific evidence supporting the use of child safety and booster seats. The American Academy of Pediatrics (AAP) has updated best practice recommendations on child passenger safety based on this evidence. There are five evidence-based recommendations to improve safety in passenger vehicles for children from birth through adolescence.
Best Practice Recommendations
INFANT-ONLY OR CONVERTIBLE CAR SEAT USED REAR FACING
Infants and toddlers should ride in a rear-facing car safety seat until they reach the highest weight or height allowed by the car seat manufacturer. They have relatively large heads and several structural neck and spine features that place them at higher risk of head and spine injuries in motor vehicle crashes. Once the highest weight has been reached using the rear-facing seat, they should continue riding rear facing in a convertible seat. Most convertible seats can be used rear-facing up to 40 lb (18 kg) and up to two years of age or longer.
CONVERTIBLE OR COMBINATION CAR SEAT USED FORWARD FACING
Children who have outgrown the rear-facing weight or height limit for their car seat should use a forward-facing seat with a harness as long as possible. Most seats are appropriate up to 65 lb (29 kg) with some having limits up to 90 lb (41 kg). Combination car seats can be used forward-facing with a harness and then as a booster seat without a harness when the highest weight and height allowed by the seat manufacturer have been reached. Some vehicle models have an integrated forward-facing seat with a harness system. A crash-tested vest can be used for children who have special needs or in certain circumstances where a car seat cannot be installed. Children with certain temporary or permanent physical and behavioral conditions may require specialized restraint systems.
BELT-POSITIONING BOOSTER SEAT
Booster seats function by positioning the child so that the lap and shoulder parts of the seat belt fit correctly. When the children have outgrown the forward-facing seat limits for the car seat, they should use a booster seat typically until they have reached 4 ft 9 in (145 cm) in height and are between eight and 12 years of age. There are three questions to determine whether a child is ready to use the vehicle seat belt without a booster seat:
Is the child tall enough to sit against the vehicle seat back with knees bent at the edge of the vehicle seat without slouching and stay in this position comfortably throughout the trip?
Does the shoulder belt lie across the middle of the chest and shoulder, not against the neck or face?
Is the lap belt low across the hips and pelvis? If the answer is no to any of these questions, the child should continue to use a booster seat.
LAP AND SHOULDER VEHICLE SEAT BELT
Lap and shoulder seat belts should always be used once children are able to use the vehicle seat belt alone. Vehicle seat belts should not be used if the lap and shoulder seat belts do not fit properly. The lap portion of the belt should fit low across the hips and pelvis, and the shoulder portion should fit across the middle of the shoulder and chest. The child is likely too small to use the vehicle seat belt if it does not fit in this manner. Children who are small for their age may need to observe rules for younger children.
All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
Guideline source: American Academy of Pediatrics
Evidence rating system used? No
Systematic literature search described? No
Guideline developed by participants without relevant financial ties to industry? Yes
Recommendations based on patient-oriented outcomes? Yes
Published source:Pediatrics. November 2018;142(5):e20182460