ARTICLE

Effectiveness of Child Safety Seats vs Seat Belts

in Reducing Risk for Death in Children
in Passenger Vehicle Crashes
Michael R. Elliott, PhD; Michael J. Kallan, MS; Dennis R. Durbin, MD, MSCE; Flaura K. Winston, MD, PhD

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 Trans-
portation Safety Administration by combining cases in-
volving a fatality from the US Department of Transpor-
tation 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 (rear-
facing and forward-facing car seats, and shield and belt-
positioning booster seats) vs seat belts. Potentially con-
founding variables included seating position, vehicle type,
model year, driver and passenger ages, and driver sur-
vival 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 re-
straint 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 ad-
justing for seating position, vehicle type, model year, driver
and passenger ages, and driver survival status. When in-
cluding cases of serious misuse, the effectiveness esti-
mate was slightly lower (21%) (relative risk, 0.79; 95%
confidence interval, 0.59-1.05).
Conclusion: Based on these findings as well as previ-
ous epidemiological and biomechanical evidence for child
restraint system effectiveness in reducing nonfatal in-
jury risk, efforts should continue to promote use of child
restraint systems through improved laws and with edu-
cation and disbursement programs.
Arch Pediatr Adolesc Med. 2006;160:617-621

Author Affiliations:
Department of Biostatistics,
University of Michigan School
of Public Health, and Institute
for Social Research, University
of Michigan, Ann Arbor
(Dr Elliott); Center for Clinical
Epidemiology and Biostatistics
(Mr Kallan and Dr Durbin) and
Divisions of Pediatric
Emergency Medicine
(Dr Durbin) and General
Pediatrics (Dr Winston),
University of Pennsylvania
School of Medicine, Leonard
Davis Institute of Health
Economics, University of
Pennsylvania, (Dr Winston),
Philadelphia; and TraumaLink
Injury Research Center,
Children’s Hospital of
Philadelphia (Drs Durbin and
Winston).
C
HILD RESTRAINT POLICY,
including the passage of
state child restraint laws,
relies on evaluation of the
risks of nonuse of child
restraint systems and the benefits of their
use in protecting children in crashes, most
notably in the form of effectiveness esti-
mates. However, previous estimates of real-
world child restraint effectiveness have var-
ied based on the analytical method chosen
(most notably, the crash database chosen
for analysis) and factors under study, in-
cluding the outcome (nonfatal injury vs
death) and the comparison group (chil-
dren restrained with seat belts vs unre-
strained children).1-6
Estimating effectiveness of child re-
straint systems through analysis of crash
databases is potentially problematic be-
cause of the association between how pas-
sengers are restrained in a given crash and
whether that crash will be in the given da-
tabase. Analyses estimating the effective-
ness of restraints are often conducted us-
ing the US Department of Transportation
Fatality Analysis Reporting System (FARS),
a census of crashes in the United States in
which at least 1 person died. FARS has a
sufficient number of outcomes of fatal child
injuries for analysis but has a potentially
biased selection of crashes in that inclu-
sion of crashes is associated with the out-
come of interest, fatalities. Using only data
from FARS to assess child restraint sys-
tem effectiveness in reducing risk for death
in passenger vehicle crashes implicitly as-
sumes that surviving children in fatal ac-
cidents have restraint practices that are
similar to those of children in other seri-
ous crashes that do not result in fatali-
ties. If child restraint systems are highly
effective in reducing risk for death rela-
tive to seat belts, children in crashes who

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 survived because they were restrained in a child re-
straint system rather than a seat belt will not be in-
cluded in the FARS database unless someone else in the
crash died. This will lead to a potential underrepresen-
tation of child restraint system use among surviving chil-
dren and a consequent underestimation of the effective-
ness of child restraint systems in reducing risk for fatal
injury if only FARS data are used.
One method for dealing with selection bias inherent
in a FARS-only analysis would be a matched case-
control or double-sampling method7 that compares out-
comes in children using different restraint types within
a vehicle. Such analyses face limitations in this setting
owing to small sample sizes, especially if other factors
such as age or seating position are also matched for. We
pursue an alternative analytical approach, that of com-
bining the FARS database with the National Automo-
tive Sampling System Crashworthiness Data System (NASS
CDS), which includes a national probability sample of
2-way crashes. The NASS CDS provides a cross-section
of crashes without regard to injury outcome but in-
cludes relatively few crashes with fatal child outcomes.
By combining data from FARS and NASS CDS, we can
obtain a sample of the entire cohort of children in-
volved in 2-way crashes in the United States during a given
period, with an identification of all of the fatally injured
children during that time. Such analysis need not rely on
assumptions about the representativeness of fatal crashes
in the entire crash population.
Using sled tests, Kahane1 previously estimated a mor-
tality risk reduction of 46% for children in child re-
straints compared with unrestrained children. Using the
double-sampling method applied to FARS data, Par-
tyka5 and Hertz6 found reductions of 47% to 59% in fa-
tality risk for children aged 1 to 4 years in child restraint
systems compared with unrestrained children. In more
recent years, child restraint and seat belt use rates have
increased dramatically.8 This study builds on the work
of Kahane,1 Partyka,5 and Hertz6 by providing a current
estimate of restraint effectiveness based on newer model
year vehicles and restraints and by providing an esti-
mate of the incremental benefit, if present, of child re-
straint systems over seat belts alone for young children.
METHODS
DATA SOURCES
A census of children involved in crashes in the 50 states, the
District of Columbia, and Puerto Rico, in which at least 1 pas-
senger in 1 of the vehicles involved in the crash died, was ob-
tained from the National Highway Traffic Safety Administra-
tion FARS database.9 To be included in FARS, a crash must
involve a motor vehicle traveling on a traffic way customarily
open to the public and result in the death of a person (occu-
pant of a vehicle or a nonoccupant such as a pedestrian) within
30 days of the crash. We restricted our analyses to the 92% of
vehicles that were nondrivable (could not be driven from the
crash scene) for compatibility with the NASS CDS. Further, to
focus on the effectiveness of current child restraint systems, only
crashes between 1998 and 2003 were analyzed. A few crashes
in which only nonoccupants died were also excluded. Because
all US state laws require child restraints for children younger
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than 2 years but some states still allow seat belt restraints for
children aged 2 years or older, this study was limited to chil-
dren from the ages of 2 through 6 years. Within FARS, we iden-
tified 7813 children aged 2 through 6 years who were vehicle
occupants restrained in a child restraint system or a seat belt
in a nondrivable passenger car, van, pickup truck, or sport-
utility vehicle that was involved in a crash with at least 1 pas-
senger fatality between 1998 and 2003. Of these 7813 chil-
dren involved in fatal crashes, 1096 children (14%) were killed.
A sample of children involved in nonfatal crashes was ob-
tained from NASS CDS.10 The NASS CDS is a representative
3-stage probability sample selected annually from all police-
reported crashes that resulted in at least 1 vehicle having to be
towed from the scene because of damage. Approximately 5000
vehicles per year were sampled as part of the NASS CDS. Both
vehicles in a NASS CDS–investigated crash were not necessar-
ily nondrivable; therefore, we restricted our analyses to the 83%
of vehicles that were nondrivable. Within NASS CDS, we iden-
tified 1433 children aged 2 through 6 years who were re-
strained in a child restraint system or seat belt in a passenger
car, van, pickup truck, or sport-utility vehicle involved in a non-
fatal crash sampled between 1998 and 2003. Because of the com-
plex sample design of NASS CDS, these 1433 children repre-
sent 956 820 children meeting our inclusion criteria.
VARIABLE DEFINITIONS
Our exposure variable of interest was child restraint system use
vs seat belt use. Child restraint systems included rear-facing
and forward-facing car seats, and shield and belt-positioning
booster seats. Our primary analysis included all children
2 through 6 years old classified as either child restraint system
or seat belt users, regardless of how the restraint was used. Our
secondary analysis excluded the small fraction of children in
FARS when the restraints were seriously misused. These in-
cluded seat belt users who used a shoulder belt without a lap
belt or improperly used the seat belt, for example, by restrain-
ing multiple children with a single seat belt, and also included
child restraint users who did not attach the restraint to the ve-
hicle seat or did not use the harness straps. Such misuse would
usually be classified as nonuse in the NASS CDS; thus, a simi-
lar restriction was not necessary for the sample from NASS CDS.
We also included driver, child, and vehicle characteristics of
seating position (front seat vs rear seat), vehicle type (passen-
ger car, pickup truck, van or minivan, and sport utility ve-
hicle), model year (before 1990, 1990-1993, 1994-1997, after
1997), driver age (⬍20 years vs ⱖ20 years), passenger age
(dummy variables for years 2-6), and driver survival status (as
a marker of crash severity) as potential confounders. Direc-
tion of impact was not ascertained consistently in the 2 data-
bases and was excluded from the analysis.
STATISTICAL ANALYSES
Bivariate analyses comparing fatalities and nonfatalities and re-
straint type with respect to crash characteristics (seating posi-
tion, vehicle type, model year, driver and passenger ages, and
driver survival status) were conducted. Robust ␹2 tests were
performed to assess the differences in distributions in the bi-
variate analyses. Logistic regression modeling was used to com-
pute the relative risk (RR) for death in children in child re-
straint systems vs seat belts. To estimate adjusted RRs, we used
odds ratios from logistic regression; odds ratios will approxi-
mate RRs when the outcome is uncommon, as it was in this
study. Because child restraint system users may differ from seat
belt users in other crash characteristics, both unadjusted and
adjusted analyses were conducted.
WWW.ARCHPEDIATRICS.COM
 Table 1. Child Occupant and Crash Characteristics, Overall and by Restraint Use*†

Characteristic Overall CRS‡ Seat Belt§ P Value

Fatality status
Fatal 0.11 (1096) 0.12 (508) 0.11 (588)
.88
Nonfatal 99.89 (8150) 99.88 (3795) 99.89 (4355)
Age, y
2 21.2 (2243) 42.8 (1875) 2.9 (368)
3 17.3 (1981) 29.3 (1338) 7.3 (643)
4 19.2 (1875) 17.8 (718) 20.4 (1157) ⬍.001
5 15.0 (1615) 7.6 (278) 21.2 (1337)
6 27.3 (1532) 2.5 (94) 48.2 (1438)
Seating position
Front seat 15.7 (1549) 13.4 (360) 17.6 (1189)
.47
Rear seat 84.3 (7697) 86.6 (3943) 82.4 (3754)
Vehicle type
Passenger car 67.7 (5003) 71.4 (2271) 64.5 (2732)
Pickup truck 5.6 (941) 3.1 (367) 7.7 (574)
.46
Van/minivan 17.2 (1688) 16.0 (861) 18.3 (827)
Sport-utility vehicle 9.5 (1614) 9.6 (804) 9.4 (810)
Model year
Before 1990 15.6 (1749) 13.0 (734) 17.7 (1015)
1990-1993 23.4 (1953) 23.4 (893) 23.3 (1060)
.73
1994-1997 33.8 (2692) 37.2 (1259) 31.0 (1433)
1998-2004 27.2 (2852) 26.4 (1417) 28.0 (1435)
Driver age, y
⬍20 4.0 (603) 3.4 (268) 4.5 (335)
.71
ⱖ20 96.0 (8643) 96.6 (4035) 95.5 (4608)
Driver fatality
Yes 0.28 (2744) 0.29 (1299) 0.28 (1445)
No 99.72 (6502) 99.71 (3004) 99.72 (3498) .70
Total 45.7 (4303) 54.3 (4943)

Abbreviations: CRS, child restraint system; FARS, Fatality Analysis Reporting System (US Department of Transportation); NASS CDS, National Automotive
Sampling System Crashworthiness Data System.
*Data are based on combined FARS/NASS CDS data set for crashes occurring between 1998 and 2003. Data are weighted according to their probability of
selection: FARS cases with weights of 1; NASS cases with weights proportional to the inverse of their probability of selection.
†Data indicate weighted percent (unweighted number).
‡Includes 162 subjects with serious CRS misuse.
§Includes 89 subjects with serious seat belt misuse.

Because sampling in NASS CDS was based on model year and

the severity of injury (including hospitalization status), subjects
in less serious crashes were underrepresented in the study sample
in a manner potentially associated with the predictors of inter-
est. To account for this potential bias, case weights equal to the
inverse of the probability of selection and adjusted to known crash
totals were used to account for the oversampling of serious crashes
in NASS CDS. (Case weights in FARS were set to 1, consistent
with FARS being a census of all fatalities.) To adjust inference to
account for the disproportional probability of selection of sub-
jects and stratification and clustering of subjects by geographic
region and vehicle, robust ␹2 tests of association and Taylor se-
ries linearization estimates of the logistic regression parameter vari-
ances were calculated using SAS-callable SUDAAN: Software for
the Statistical Analysis of Correlated Data, version 9.1 (Research
Triangle Institute, Research Triangle Park, NC).
RESULTS
Data in the cohort (constructed as described earlier) in-
cluded 9246 children, weighted to represent 964 633 chil-
dren in nondrivable vehicles in crashes between 1998 and
2003. Table 1 gives the distribution of the variables used
in the analysis, overall and by type of restraint used. Ap-
proximately 1 (0.11%) of 1000 children in a 2-way crash
Table 2. Relative Risk for Death, Child Restraint System
Use vs Seat Belt Use, Unadjusted and Adjusted
for Seating Position, Vehicle Type, Model Year,
Driver and Passenger Age, and Driver Death
Unadjusted Adjusted
Variable RR (95% CI) RR (95% CI)
All restrained 1.03 (0.72-1.46) 0.79 (0.59-1.05)
Excluding serious 0.93 (0.65-1.32) 0.72 (0.54-0.97)
misuse of restraint
Abbreviations: CI, confidence interval, RR, relative risk.
died. Somewhat fewer than half (45%) of all children were
in child restraint systems, although younger children were
much more likely to be restrained in child restraint sys-
tems. One (15.7%) of 6 children were in the front seat,
two thirds (67.7%) were in passenger cars, one (15.6%)
of 6 were in pre-1990 model year vehicles, and relatively
few (4.0%) were driven by teenaged drivers; none of these
factors were significantly associated with restraint type in
bivariate analyses.
Table 2 summarizes little difference in the unad-
justed risk for death between users of child restraint sys-

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 tems and users of seat belts (RR, 1.03; 95% confidence
interval, 0.72-1.46). After adjusting for seating posi-
tion, vehicle type, model year, driver and passenger ages,
and driver survival status, children in child restraint sys-
tems had a 21% reduction in risk for death compared with
children in seat belts, although this difference was only
marginally significant (RR, 0.79; 95% confidence inter-
val, 0.59-1.05). After excluding the cases of serious child
restraint system and seat belt misuse from FARS, chil-
dren in child restraint systems had a 28% reduction in
risk for death compared with children in seat belts (RR,
0.72; 95% confidence interval, 0.54-0.97).
COMMENT
Our analysis indicated that children aged 2 through 6 years
in child restraint systems had a 21% reduction in mor-
tality risk compared with children in seat belts. When
cases of serious misuse of child restraint systems and seat
belts are excluded, mortality risk was reduced by 28%.
This effectiveness estimate is less than that reported by
Kahane,1 Partyka,5 and Hertz,6 all of whom compared mor-
tality risk in children in child restraint systems with those
who were not restrained. Hertz6 conducted the most re-
cent National Highway Transportation Safety Adminis-
tration effectiveness analyses based on crashes between
1988 and 1994. Using a matched-pairs analysis, he found
that, among children aged 1 to 4 years in passenger cars,
those in child restraint systems experienced a 54% re-
duction in deaths compared with unrestrained chil-
dren. In the same analysis, Hertz6 found that children in
seat belts experienced a 47% reduction in deaths com-
pared with unrestrained children. The crude relative ef-
fectiveness of child restraint systems vs seat belts based
on this analysis would be 0.54 divided by 0.47, or 1.149,
a 14.9% improvement in mortality reduction afforded by
child restraint systems over seat belts.
In a more recent series of analyses, Levitt4 and Dub-
ner and Levitt11 used FARS data from 1975 to 2003 and,
by various methods, directly compared the mortality with
child restraint systems vs seat belts in children aged 2 to
6 years and could not demonstrate a difference in effec-
tiveness. Levitt and Porter12 restricted the FARS data set
to 2-vehicle crashes in which someone in the other ve-
hicle (ie, the vehicle without the index child occupant)
died, under the assumption that the distribution of re-
straint use among children in potentially fatal crashes is
independent of whether someone in the other vehicle dies,
after adjusting for various crash-related characteristics.
The precision of these previous effectiveness esti-
mates and their relevance to today’s fleet were limited by
their reliance on FARS (the limits of which were pre-
sented in the introduction), by the inclusion of older ve-
hicles and restraints, and by failing to control for the se-
verity (potential unsurvivability) of the crashes. Our
analysis based on a modern cohort of children involved
in crashes in which the car was rendered undrivable ad-
dressed many of the limitations of these previous analy-
ses and found effectiveness estimates for child restraint
systems to be greater than that for seat belts alone, with
estimates greater than those of both Levitt4 and Hertz.6
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Child restraint systems offer a considerable safety ad-
vantage over seat belts alone for biomechanical reasons.
Child restraint systems are designed to reduce risk for ejec-
tion during a crash, better distribute the load of the crash
through structurally stronger bones rather than soft tis-
sues, limit the crash forces experienced by the vehicle oc-
cupant by prolonging the time of deceleration, and po-
tentially limit the contact of the occupant with intruding
vehicle structures. Optimal performance of restraint sys-
tems depends on an adequate fit between the restraint sys-
tem and the occupant at the time of the crash. Increased
risk for injury in young children restrained in seat belts
as a result of improper loading of deceleration forces has
been documented for nearly 50 years.13-15 Child restraint
systems offer improved fit of restraints for children who
are too small for the adult-sized seat belt, thereby afford-
ing a mechanical protection advantage over seat belts. If
restraint systems are seriously misused, however, their
safety performance would be expected to be diminished.
We adjusted for serious seat belt and child restraint sys-
tem misuse (as defined in the “Methods” section) and found
a slight increase in the relative effectiveness of child re-
straint systems compared with seat belts. In addition, pre-
vious in-depth analyses have demonstrated that most
crashes in which children in child restraint systems die
were of such severity that survival of the child was un-
likely.16,17 Considering this, we included a variable for driver
death (as a proxy for a potentially nonsurvivable crash)
in our multivariate analyses.
Previous assessments of child restraint system effec-
tiveness using nonfatal injury as an outcome have dem-
onstrated the safety benefits of child restraint systems over
seat belts alone for young children.2,3,17 The current study
extends this evidence to include increased effectiveness
of child restraint systems over seat belts alone in pre-
venting death.
Our analysis was not without limitations. Restraint sta-
tus information was missing for approximately 6% of chil-
dren aged 2 through 6 years in the FARS data set and 9%
of such children in the NASS CDS data set. Systematic
differences between these subjects and those with re-
straint status provided may bias results, although the effect
of such bias is likely to be small, given the relatively small
amount of missing data. (Among restrained children aged
2 through 6 years, seating position was missing in 4% of
FARS cases and less than 1% of NASS CDS cases, and less
than 1% in both data sets were missing driver survival
status, driver age, vehicle type, or model year.) In addi-
tion, the possibility of differential misclassification bias
exists. Thus, if police misclassified fatally injured chil-
dren in restraint systems as being in seat belts or unre-
strained less often than NASS CDS crash investigators did
for survivors of passenger vehicle crashes, the resulting
RR for children in child restraint systems vs seat belts
would be biased upward (ie, toward 1). Previous work
suggests that, when a crash involves a fatality, the valid-
ity of police-reported restraint use improves.18 There-
fore, to the extent that misclassification in restraint use
exists in our sources of data, it is more likely that it may
result in an underestimate of child restraint system ef-
fectiveness. Finally, while we have argued that using only
the FARS data set puts one at risk for selection bias, use
WWW.ARCHPEDIATRICS.COM
 of the NASS CDS to obtain a representative sample of the
full two-way crash population may suffer from confound-
ing between child restraint system use and crash sever-
ity, leading to either upward or downward bias in the es-
timate of child restraint system effectiveness. For example,
if drivers who restrain their children in child restraint
systems are less likely to be involved in potentially fatal
crashes (ie, those fatal with the child in either a child re-
straint system or a seat belt, in a child restraint system
only, or in a seat belt only), use of the NASS CDS popu-
lation may overstate the effectiveness of child restraint
systems vs seat belts by confounding child restraint use
with safer driving behavior. The restriction of NASS CDS
to two-way crashes and use of adjustment factors such
as vehicle type, model year, age of driver, and, espe-
cially, survival status of the driver should reduce this con-
founding.
IMPLICATIONS
Our analysis, which considered key predictors other
than restraint use that are associated with injury sever-
ity and addressed selection bias problems inherent in a
FARS-only analysis by combing FARS and NASS CDS
data into a single cohort, provides evidence that using
child restraint systems rather than seat belts reduces
mortality in children aged 2 through 6 years. Based on
our current findings as well as the long-standing biome-
chanical evidence for child restraint effectiveness and
previous demonstrations of the importance of child re-
straint systems in reducing nonfatal injury risk,3,19 ef-
forts should continue to promote child restraint use
through improved child restraint laws and with educa-
tion and disbursement programs. Further research is
needed, however, to further refine restraint effective-
ness estimation procedures and to ensure that the re-
sults are applicable to the current fleet, because this in-
formation is needed for evidence-based policy and
product design.
Accepted for Publication: November 23, 2005.
Correspondence: Flaura K. Winston, MD, PhD, 3535
TraumaLink Injury Research Center, 10th Floor, Children’s
Hospital of Philadelphia, 34th St and Civic Center Blvd,
Philadelphia, PA 19104 (flaura@mail.med.upenn.edu).
Funding/Support: We acknowledge the commitment,
partnership, and financial support of State Farm Mutual
Automobile Insurance Company for the conduct of this
research study.
“I just can’t get over how much babies cry.
I really had no idea what I was getting into.
To tell you the truth, I thought it would be
more like getting a cat.”
—From Operating Instructions by Anne La-
mott, 1993
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Disclaimer: The results presented in this report are the
interpretation solely of the authors and are not neces-
sarily the views of State Farm Mutual Automobile Insur-
ance Company.
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Correction

Incorrect Terminology. In the article titled “Effective-

ness of Child Safety Seats vs Seat Belts in Reducing Risk
for Death in Children in Passenger Vehicle Crashes,” by
Elliott et al published in the June issue of the ARCHIVES
(2006;160:617-621) the term tow-away was incorrectly
changed to the term two-way. Thus, on page 617, in the
“Participants” subsection of the “Abstract,” the sen-
tence should have read as follows: “Children in tow-
away crashes occurring between 1998 and 2003.” The
same error occurred on page 621, left-hand column, lines
1 and 2. These should have read “ . . . of the NASS CDS
to obtain a representative sample of the full tow-away
crash population may suffer from confounding. . . . ” Fur-
ther down on the same page and in the same column,
the last sentence of that paragraph should have read as
follows: “The restriction of NASS CDS to tow-away
crashes and use of adjustment factors such as vehicle type,
model year, age of driver, and, especially, survival sta-
tus of the driver should reduce this confounding.”

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