Car crashes are the leading cause of death among children in the United States, according to the Centers for Disease Control and Prevention, but when safety guidelines are followed, many of these deaths can be prevented.
In 2021, more than 700 children ages 12 and younger were killed in crashes — 36% of them were not buckled up. And new research shows that many parents move their kids out of their booster seats before they are ready, increasing the risk of injury and death.
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Safety guidelines state that children must be at least 4 years old, weigh at least 40 pounds and be mature enough to remain seated the entire ride to transition from a 5-point harness car seat to a booster seat. However, experts recommend waiting until children have outgrown the height or weight limits of their car seats before making the move.
Once transitioned, children should remain in their booster seats until they are at least 4 feet, 9 inches. Children typically reach that heigh between ages 8 and 12.
A surprising disconnect
Research has shown that car seats reduce the risk of injury during collisions by almost 80% when compared with just the use of a seatbelt. And a booster seat reduces the risk of injury for children ages 4-8 by almost 50%, according to the CDC.
Yet, a recent study found that 4 of 5 parents moved their children out of a booster seats before their children were tall enough. And 3 of 4 parents don't realize kids should stay in booster seats until they're at least 4 feet, 9 inches.
When smaller children ride with only a seat belt to secure them, they are at risk for abdominal, head and spinal injuries when involved in car crashes, according to the study, conducted by Safe Kids Worldwide, an organization that works to reduce unintentional injuries to children, and Ohio State University researchers.
The study was based on the results of an online survey of 3,026 parents and caregivers with children ages 4-10. Most of the questions focused on the use of booster seats and the awareness of how long children should remain in them. The survey also asked questions about behaviors related to carpooling and school drop-offs and pick-ups.
About 30% of the caregivers who drive carpools reported letting children ride unbuckled, and many of them admitted to not always following safety rules to make school drop-offs and pick-ups more smooth.
The researchers said stronger advocacy efforts are needed to better educate families on keeping their children safe.
"Our goal is for every child to be appropriately restrained for every ride," Dr. Julie Mansfield, research associate professor at Ohio State's Injury Biomechanics Research Center, said in a statement. "Achieving that mission requires an understanding of how families make decisions and identifying effective ways to foster growth."
'Peer pressure has a major influence'
Stephanie Porco, a trauma prevention coordinator at the Children's Hospital of Philadelphia, stresses the importance of proper booster seat use while acknowledging the challenges faced by parents.
"An improperly fit seatbelt is dangerous for people of all ages," Porco said. "We emphasize height because a seatbelt must fit correctly to work as intended and passengers must be 4 feet, 9 inches to achieve correct fit. Children grow at a speed that's appropriate for their body. On average, children in America don't magically reach 4 feet, 9 inches on their eighth birthday."
The National Highway Traffic Safety Administration reports that children ages 8-12 often are found to be using the wrong type of restraint for their ages and sizes, she said. In 2022, this age group had the highest number of deaths among children in car crashes.
Porco acknowledged that keeping smaller-sized children in their booster seats when their friends no longer use them can be challenging.
"Peer pressure has a major influence," Porco said. "Especially if a child is self-conscious about their size or feels babied."
Parents like Rachel Holt, of Jenkintown, and Melissa Prushan, of Philadelphia, understand these challenges and the importance of proper child passenger safety.
Holt has a son and a daughter who always have been small for their ages. Her daughter, now 12, was in a booster seat until age 11, the beginning of sixth grade. Her son, 9, is still in a high-back booster seat, because he falls asleep in the car.
Hart said she has been very strict in following the safety rules because of her own traumatic experience as a child. She and her older sister Heather were in a car crash caused by a drunk driver, and Heather, an eighth grader, died as a result of her injuries.
"It certainly shaped who I am," Hart said. "I saw how it can devastate not only a family, but a whole community.
"From my own personal experience, cars are weapons and accidents most often occur close to home. I tell my kids, 'if you were a parent, wouldn't you do everything you could to protect your children?'"
She acknowledged that her kids get very embarrassed about having to use booster seats, but for her, it is a hard stop.
"I explain to them what could happen without scaring them," Hart said. "I show them where the seatbelt sits and the impact of a crash on the body."
Prushan, the mother of two daughters, was in a car crash with her younger daughter, who is now 17, while driving her to preschool.
She recently had switched her daughter to a booster seat even though she hadn't outgrown the 5-point harness, because her daughter was feeling embarrassed. But then she ended up switching the seats back again before the day of the crash.
"She kept getting out of the booster seat while I was driving, so I put her back in the 5-point harness," Prussian said. "Thank God I did. She experienced whiplash from the accident, but it could have been worse."
How to talk to kids about car safety
To help parents explain to their kids why they need to continue using their booster seats, Porco said she often shares these talking points:
• Refrain from calling a booster seat a "baby seat" or a "car seat."
• Explain the purpose and importance of using a booster seat. Knowledge is power.
• Be consistent. A booster seat is required on every ride, in every vehicle (besides school bus) and with every driver, including carpools. No exceptions.
• Practice what you preach. Children are more likely to practice safe behaviors if their parents do as well.
Child passenger safety laws vary from state to state. In Pennsylvania, children must stay in a booster seat until age 8. In New Jersey, children under 8 who weigh less than 80 pounds must ride in a child safety seat or booster seat in the rear seat of the vehicle.
To ensure children are ready to transition to just wearing a seat belt, do a Safety Belt Fit Test first. When sitting in the car, the child should be able to sit with their back and bottom against the back of the seat. Their knees should bend at the edge of the seat with their feet touching the floor. Check to make sure the lap belt fits securely across their hips or upper thighs and that the shoulder belt lays across the shoulder and chest — not the face or neck.
More child passenger safety tips are available at safekids.org.