Effectiveness of child safety seats vs seat belts in reducing risk for death in children in passenger vehicle crashes

Objective: To provide an estimate of benefit, if any, of child restraint systems over seat belts alone for children aged from 2 through 6 years. Design: Cohort study. Setting: A sample of children in US passenger vehicle crashes was obtained from the National Highway Transportation Safety Administration by combining cases involving a fatality from the US Department of Transportation Fatality Analysis Reporting System with a probability sample of cases without a fatality from the National Automotive Sampling System. Participants: Children in two-way crashes occurring between 1998 and 2003. Main Exposure: Use of child restraint systems (rearfacing and forward-facing car seats, and shield and belt-positioning booster seats) vs seat belts. Potentially confounding variables included seating position, vehicle type, model year, driver and passenger ages, and driver survival status. Main Outcomes Measure: Death of child passengers from injuries incurred during the crash. Results: Compared with seat belts, child restraints, when not seriously misused (eg, unattached restraint, child restraint system harness not used, 2 children restrained with 1 seat belt) were associated with a 28% reduction in risk for death (relative risk, 0.72; 95% confidence interval, 0.54-0.97) in children aged 2 through 6 years after adjusting for seating position, vehicle type, model year, driver and passenger ages, and driver survival status. When including cases of serious misuse, the effectiveness estimate was slightly lower (21%) (relative risk, 0.79; 95% confidence interval, 0.59-1.05). Conclusion: Based on these findings as well as previous epidemiological and biomechanical evidence for child restraint system effectiveness in reducing nonfatal injury risk, efforts should continue to promote use of child restraint systems through improved laws and with education and disbursement programs.