A 13-month-old boy arrives by EMS after a motor vehicle accident. He was a rear passenger, restrained in a front-facing car seat when the vehicle struck a utility pole at high speed. Initially, he was responsive and crying, but became unresponsive and lost vital signs en-route to the ED. In the trauma bay, ROSC is achieved after a brief period of CPR and airway management. His imaging is notable for significant fractures at C1/C2 as well as complex ligamentous disruption; he requires emergent surgical intervention for his spinal injuries, and suffers a severe anoxic brain injury.
Two boys, a 4-month-old and a 3-year-old, arrive by EMS after a low speed, T-bone motor vehicle accident with airbag deployment. Both patients were restrained rear passengers, the 4-month-old in a rear-facing seat, and the 3-year-old in a front-facing seat. In the ED, exam is significant only for some mild abrasions, and both are discharged after a period of observation. The car seats involved in the accident are brought to the ED, and family attempts to use them to transport the children home.
A 5-year-old girl arrives by EMS unresponsive after a front-end collision. She was restrained in her front-facing car seat, when the vehicle struck a telephone pole. Per EMS providers, the seat was not properly restrained within the vehicle. She is apneic with obvious, severe head injuries and asymmetric pupils, with imaging confirming multiple skull fractures and intracranial hemorrhage. Despite maximal interventions, she succumbs to her injuries.
A new mother brings her 31-day-old infant for evaluation of vomiting. An exam is performed and is reassuring, consistent with likely reflux, and she is discharged home with close pediatrician follow up in the coming days. On the way out of the exam room, she asks if her car seat is safe to use, as it was a hand-me-down from another family member, and she is not sure if this seat is “expired.”
Unintentional injuries remain a leading cause of death in children. While the number of fatalities from motor vehicle collisions has declined, it remains the cause of death in 1 out of 4 children ages 1-13 . Car safety seats (CSS) have been demonstrated to reduce the risk of injury and death in children, and are credited with saving the lives of 328 children under age 4 in 2016 . Currently, laws exist in all 50 states and Washington D.C. governing the use of child safety seats. The use of car safety seats has been well studied by multiple agencies, including the National Highway Traffic Safety Administration, the Center for Disease Control and Prevention, the Insurance Institute for Highway Safety, and the American Academy of Pediatrics.
We have a duty to our pediatric patients and their families to be familiar with the current recommendations for car safety seats, and provide education and resources when necessary to help prevent morbidity and mortality. In two of the above cases, provider knowledge about these recommendations is critical, and allows rapid intervention on discharge to prevent possible further injuries. As unfortunately common to practitioners in the emergency department, the remaining two cases help reinforce the need for a high index of suspicion for injuries when children present with a history consistent with improper restraint.
Current Recommendations [3,10]:
The American Academy of Pediatrics recently released a policy statement published November 2018, highlighting the current recommendations for child safety seats. A summary of recommendations along with a useful flow chart is shown below*:
All infants and toddlers should ride in a rear-facing car seat as long as possible, until they reach the height or weight limit listed by the car seat manufacturer
It is important to check which type of seat is used rear-facing: infant-only seats have a much lower height and weight limit than convertible or 3-in-1 car seats
All children that have outgrown the height or weight limit on a rear-facing seat should ride in a forward-facing seat with a harness until they reach the height/weight limit listed by the manufacturer
When children outgrow the height or weight limit of a forward-facing seat, they should use a booster seat until the vehicle lap and shoulder belt fits appropriately, typically when they reach a height of 4 feet 9 inches, and between the age of 8-12
When children are old/tall enough to use the vehicle seat belt alone, they should always use both a lap and shoulder belt
All children under age 13 should remain restrained in the back seat for optimal protection
*Modified from Table 1: Summary of Best Practice Recommendations, Durbin and Hoffman, Pediatrics, Vol 145 No 5, November 2018
Algorithm to guide implementation of best practice recommendations for optimal child passenger safety:
For the visual learners, the CDC has a graphical representation of the seats with corresponding ages:
In Rhode Island, specific laws were enacted in 2017, outlining the proper restraint of passengers in vehicles, including children, with a pertinent summary below :
All children under age 8, less than 57 inches in height (4 feet 9 inches), and less than 80 pounds should be restrained in a rear sitting position in an approved child restraint system
All infants and toddlers less than 2 years of age, or weighing less than 30 pounds, should be restrained in a rear-facing car seat
All children 2 years of age or older who outgrow rear-facing car seats should use a forward-facing car seat with harness, up to the maximum allowed by the car seat manufacturer
Frequently Asked Questions:
I have a car seat and am not sure it is installed properly, or am expecting a new baby and not sure how to install my car seat. Where can I go to make sure this is done correctly?
There are several options to ensure a child safety seat is installed correctly. The easiest way to do this is to simply search through the National Child Passenger Safety Certification webpage, listed below for a car seat check station. Several options exist, including locating a local agency that will perform a car seat check/installation teaching (most often a local police or fire department), attending a child safety event, or locating a specific inspection station not included in the above . Many children’s hospitals, such as Hasbro Children’s Hospital, also have staff certified for safe car seat installation.
I received a car seat as a hand-me down from another family member, but heard car seats expire. Is this true, and how can I tell if this seat is okay?
This is an important, sometimes overlooked fact of child safety seats. While both vehicle and car seat technology have dramatically improved the safety of children riding in vehicles, there are limitations of the seats. Most car seats carry an expiration date 6 years after the manufacture date (although this may vary slightly based on seat construction) . The primary reason for this is the wear and tear placed on the seats themselves, including temperature variation, spills, and physical wear from use of the seat. It is also important to recognize that new technology is continually being produced, which quickly makes older seats less superior in safety. Find the label on the child’s seat, which will list both the manufacture date and expiration date. An example of a label can be found below, as seen in a blog post about this topic from Cincinnati Children’s Hospital :
An additional checklist is provided in the “Additional Resources” section below that should be reviewed before purchasing, and using a used car seat
My child was involved in a car accident in a car seat. Is this seat safe to use after the accident?
The National Highway Traffic Safety Administration has some guidelines for when a car seat should be replaced. In cases of minor accidents, a car seat does not necessarily have to be replaced, but the accident must meet all of the following criteria :
Vehicle was driven away from crash site
Vehicle door nearest car seat was not damaged
No passengers in the vehicle sustained injuries
No airbag deployment in the vehicle
The car seat has no obvious damage
If there is any doubt about the severity of the accident, or of the integrity of the car seat, the safest option is to replace the seat
Is there anything else I should do after purchasing a car seat to help ensure it remains up-to-date?
Like all new technology, product failures sometimes happen, requiring replacement parts or adjustments. After purchasing a car seat, it is important to register the seat with the appropriate manufacturer to ensure prompt notification of any recall notices in a timely manner. Most manufacturers provide a card that can be submitted, which can also be done online through the specific manufacturer’s page, or using the finder link on the National Highway Traffic Safety Administration website.
* A special thank you to the providers, nurses, staff, and most importantly, patients/families at Hasbro Children’s Hospital, and to my faculty reviewer, Dr. Jane Preotle
Faculty Reviewer: Jane Preotle, MD
Insurance Institute for Highway Safety, Highway Loss Data Institute, accessed at: https://www.iihs.org/iihs/topics/t/child-safety/fatalityfacts/child-safety, posted December 2017.
US Department of Transportation, National Highway Traffic Safety Administration, “Quick Facts 2016”, accessed at: https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812451
Durbin, DR, Hoffman, BD; “Child Passenger Safety”, AAP Council on Injury, Violence, and Poison Prevention Policy Statement, Pediatrics, Volume 142, No. 5, November 2018
Rhode Island State Police, Department of Public Safety, “Seat belt laws and car seat recommendations”, accessed at: http://risp.ri.gov/safety/vehiclesafety/seatbelts.php
National Child Passenger Safety Certification webpage, accessed at: https://cert.safekids.org/get-car-seat-checked
National Safety Commission Alert, published October 2011, accessed at: http://alerts.nationalsafetycommission.com/2011/10/child-safety-seats-have-expiration-date.html
Cincinnati Children’s Blog, “Car seat expiration dates: have you checked yours?”, published online June 22, 2015, accessed at: https://blog.cincinnatichildrens.org/safety-and-prevention/car-seat-expiration-dates-have-you-checked-yours/
National Highway Traffic Safety Administration, “Car seat use after a crash”, accessed at: https://www.nhtsa.gov/car-seats-and-booster-seats/car-seat-use-after-crash
Centers for Disease Control and Prevention, Child Passenger Safety summary page, accessed at: https://www.cdc.gov/features/passengersafety/index.html
Car Seats: Information for Families, accessed at: https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx