All 50 states now mandate the use of car safety seats or safety belts for children riding in motor vehicles.

These restraints prevent thousands of injuries and save at least 200 lives each year. Their effectiveness, however, depends heavily on parents to choose an appropriate car safety seat and then use it correctly. The parent handout on the following pages was prepared by three experts in pediatric automotive safety to help you educate parents about car safety seats. It explains the importance of the places in protecting children from injury and provides guidelines for selecting and using the seats. The handout may be photocopied and distributed to parents without the permission of the publisher.

DR. BULL is a professor of pediatrics, Indiana University School of Medicine, and director of the Automotive Safety for Children Program, James Whitcomb Riley Hospital for Children, Indianapolis.

DR. BRUNER STROUP is a research associate and coordinator for the Automotive Safety for Children Program.

MS. DOLL is the associate coordinator for the Automotive Safety for Children Program.

Selecting and using car safety seats
If you travel with an infant or small child, buying an appropriate car safety seat and using it correctly are essential investments of time and money. The information presented here can help you think through your needs, your child’s needs, and your family’s needs to determine which seat is best for your child. It also shows you how to use a car safety seat properly and effectively.

Why does your child need a car safety seat?
Motor vehicle accidents are the leading cause of injury and death among young children.
A child who is not buckled up can be thrown out of the vehicle or into other passengers, possibly injuring or killing himself or another person.
Correctly used car safety seats are 71% effective in reducing fatalities and 67% effective in preventing injuries.
Among children four years of age and under, car safety seats prevented an estimated 28,000 injuries and saved 200 lives in 1988.
The cost of earning for a child who is injured because of failure to use a car safety seat far exceeds the expense of purchasing a seat for $40 to $70.
Every state in the United States requires that young children in cars be restrained in safety seats or with safety belts. Failure to comply with child restraint laws can result in a fine or court appearance. To find out about your state’s child restraint law, contact your local or state police.
Your child depends on you to protect him when he rides in a car. Only you can make the decision to ensure that he travels safely.
This guide was prepared by Marilyn J. Bull, MD, Karen Bruner Stroup. Ph.D., and Judith P. Doll, MS, of the Automotive Safety for Children Program, James Whitcomb Riley Hospital for Children, Indianapolis.

How a car safety seat protects your child
Car safety seats are designed with a hard outer shell to protect your child’s head, neck, and back during a collision. Harness straps are placed across your child’s strongest bone structures, the shoulders, and hips. The straps hold your child in the car seat and help spread the force of an impact evenly over his entire body, which reduces the chances of injury. A plastic retainer clip helps to hold the straps in place over your child’s shoulders and secure him in the seat. Many car seats have a combination of harness and shield restraint. The shield, designed as a lap pad or padded tray, provides cushioned protection over the stomach and pelvis.

Some older car safety seats and some safety restraints for children with special medical needs have a tether strap that holds the safety seat or restraint upright against the seat of the vehicle. The tether is bolted into a solid metal part of the car. If a car safety seat requires a tether, the tether must always be used.

Which car safety seat should you buy?
Before buying a car safety seat, consider the following questions:
What are the child’s height, weight, and age? Until your child weighs at least 20 pounds and can sit up by himself. Use an infant-only or convertible car safety seat. Your child should remain in a convertible seat until he exceeds the height and weight requirements for the device, which are usually 40 inches and 40 pounds. Once the child’s shoulders are above the upper harness slots, the straps compress the shoulder and spine downward. At that point, the child should use a booster safety seat, which protects children who weigh around 30 to 60 pounds. Ideally, your child should not use a booster seat until he has outgrown a convertible safety seat because the convertible seat provides support for his head, neck, and back. When your child’s ears are above the back of the vehicle seat, he should use the regular vehicle safety belt instead of a booster seat.

• Does your child have any special problems that might prevent the use of some standard car safety seats?
• What does the owner’s manual for your car say about using a car seat with your vehicle’s seat belts?
• Will the safety belts in your car restrain a car safety seat correctly?
• Will the car seat fit on the seat of your vehicle?
• How much do you want to spend? A new car safety seat will cost $40 to $70. Used seats can be obtained for less, but make sure that any used or borrowed seat was manufactured after January 1981. Car Safety seats made before that date have not been tested against the current safety standards and may fail to protect your child in a crash. Also, make sure that no parts are missing and that all parts are in working order. If parts are not available from the manufacturer, do not use the seat. You should also have a copy of the manufacturer’s instructions. Check to see if any recalls or safety notices have been issued on the seat by calling the National Highway Traffic Safety Administration at 1-800-424-9393.
• Have you visited stores in your community or consulted a local car seat loan program to see the full range of seats available? Many loan programs are available at hospitals, health departments, police departments, and American Red Cross chapters.
• Is a seat with a five-point harness system or a harness-shield combination appropriate for your child? Try placing your child in both types of seats before choosing one. The five-point harness system, which secures the child with harness straps at both shoulders, the hips, and between the legs, maybe more time-consuming to adjust to a proper fit than a harness-shield combination. Infants weighing less than six pounds and children wearing eye-glasses should not use a seat with a harness-shield or armrest.
• Does your family need more than one car safety seat? Are you a two-career or two-car family, for example; Do you need an additional seat to use when your child is with other family members or a babysitter?
• Does your car have safety belts for all passengers?

How to use a care safety seat correctly.
If you use a car safety seat incorrectly, your child could be injured or killed in a collision. Follow the manufacturer’s instructions exactly.
When placing your child in the safety seat, remember to:

• Have your child wear clothes that allow his legs to separate so that the harness can be appropriately adjusted and snugly.
• Place rolled blankets or towels on both sides of a small infant to support his trunk and keep him centered in the car seat.
• Place a rolled cloth at the infant’s crotch to help keep him from slouching in the seat.
• Position your infant’s hips and buttocks flat against the back padding of the seat so that his head, neck, and back are up against the padding.
• Adjust the seat’s harness so that there is no more than a two-finger-breadth distance between the child’s chest bone and the straps. If the harness straps are not secured snugly, the forces of a crash will be distributed unevenly over your child’s body, increasing the risk of injury.
• Place the retainer clip at mid-chest to hold the harness straps in place on the child’s shoulders. Do not place the clip near the throat or abdomen.
• Double-check the manufacturer’s instructions to make sure the harness straps and retainer clip are secured correctly.

Before putting the vehicle in motion, ask yourself the following questions:

• Is the car safety seat anchored to the seat of your vehicle with the vehicle’s safety belt? Is the safety belt routed through the car seat in the position marked on the seat by the manufacturer?
• If your child travels in a pickup truck, make certain that there are enough safety belts for everyone. To add belts, consult the appropriate car or truck dealer.
• Is the car safety seat secure? Firmly push the safety seat up against the seat of the vehicle. Once the safety belt is routed through the appropriate area of the car seat frame, pull the belt tight.
• Is the car safety seat facing the appropriate direction for your child’s height, weight, and age? Until your child is able to sit up by himself (around nine months to 1 year), the seat should face the rear of the car. Keep your child facing rearward for as long as possible up to 1 year – to ensure maximum protection for his head, neck, back, and fragile internal organs by the sturdy outer shell of the safety seat.
• If you are using a convertible safety seat, keep the harness straps in the lower harness slots, even if your child’s shoulders are above the slots, to prevent your child from sliding up the back of the safety seat during impact. When the child is sitting up unsupported and weighs at least 20 pounds, you can turn the convertible seat forward and move the harness straps to the upper slots.
• Are the harness straps tightened so that your child is secured in the safety seat?
• Is the retainer clip positioned in the mid-chest area?
• Are the child’s hips positioned against the back of the car seat? If your child is in a booster-type safety seat, is he sitting up straight against the back of the seat of the vehicle?
• If your child uses a regular vehicle safety belt, is he positioned properly? Improper use of safety belts can contribute to injuries.
  Position the lap belt low on the child’s pelvis so that it does not ride upon the soft abdominal area. Place his buttocks firmly against the back of the vehicle seat. If the child is riding in the front seat and the shoulder belt crosses his face or neck, do not put the belt behind the child or underneath his arm. Instead, place the child’s buttocks toward the middle of the vehicle seat to help lower the shoulder belt to chest level. Or use a booster safety seat to raise the child so that you can position the lap-and-shoulder belt properly.
• Using a booster seat with side handles allows better placement of the lap-and-shoulder belt.
• If an accident does happen, check the manufacturer’s instructions. Most recommend discontinuing the use of a safety seat after a crash.

Caring for your child’s car seat
Clean vinyl-covered safety seats with mild soap and water.
Always keep the harness straps clean with soap and water so they can be easily manipulated and adjusted to lie flat against the child. Twisted or dirty straps make it difficult to adjust the harness system properly. Since infants and children do not have wide shoulders, the straps must lie flat to stay on the shoulders and distribute crash forces evenly.
Promptly replace any missing parts on the seat-such as buckles, harness straps, padding, or retainer clip-by contacting the manufacturer.

You may want to purchase a commercial seat cover appropriate for the size and brand of your car seat. A blanket or towel can also serve as a seat cover, but only if you cut holes for the harness system.

Car safety seats for children with special needs
Many infants and children with orthopedic, neurological, and respiratory problems are unable to use a standard car safety seat or seat belt. Restraints are available that can provide safe travel in any type of motor vehicle for children with special needs. It is best to investigate commercially-available restraints rather than altering standard car seats or using makeshift restraints. Ask your pediatrician for more information on special car seats.