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Car seats a must for the young
The first child I tried -- and failed -- to resuscitate in an emergency room was a 2-year-old Navajo boy whose spine had been sheared in a car crash. Like many poor kids on the reservation where I first worked as a pediatrician, this child hadn't been riding in a car seat.
Each year, car and truck accidents kill more kids than cancer, birth defects, or heart problems -- making crashes the single leading cause of pediatric deaths. Studies of the federal Fatality Analysis Reporting System, which contains data from tens of thousands of fatal accidents, show that restraining devices -- including seat belts and car seats -- cut a child's risk of dying in half.
Based on data from the National Highway Traffic Safety Administration and other studies, the American Academy of Pediatrics now recommends that all children ride in rear-facing car seats until they are a year old and weigh 20 pounds, then switch to front-facing car seats until they weigh about 30 pounds. After that, they should use a ''belt-positioning" booster seat until a regular seat belt fits properly. That, experts say, is when the lap belt sits low on the waist, the shoulder belt goes across the mid-chest, and a child's knees bend at the edge of the seat when sitting back -- usually not until a child is 8 to 10 years old.
Despite the evidence, there has been a steady drumbeat of criticism directed at these recommendations, and states have been slow to adopt them. In 2001, the Insurance Institute for Highway Safety worried that guidelines regarding booster seats were ''getting ahead of science." Last July, Freakonomics authors Stephen Dubner and Steven Levitt, analyzed FARS and claimed car seats were no better than plain seat belts for most kids and weren't ''the safety miracle that parents have been taught to believe." Only 10 state laws follow the AAP guidelines fully; Massachusetts requires car seats only through 4 years of age.
The arguments against comprehensive car restraint laws often misinterpret the data -- and obscure the real challenges in preventing collision-related injuries.
For example, Dubner and Levitt are correct that the FARS data show no survival difference between car seats and ordinary seat belts for kids over 2. But this is misleading because the FARS includes only fatal accidents. Non-fatal accidents involving kids in car seats aren't included, though these are 100 times more common than fatal collisions.
Looking at a more comprehensive database involving insurance claim records instead of fatal accident reports, Dr. Flaura Winston of Children's Hospital in Philadelphia found that booster seats instead of seat belts made all injuries 60 percent less likely for 4- to 8-year-olds. For 1- to 4-year-olds in car seats instead of seat belts, the overall harm reduction was an even more impressive 70 percent, according to a different study.
Overall, Winston's data for these children shows that roughly 4 percent wearing no restraints are injured in a crash, compared with 2 percent of those wearing just a seat belt, and less than 1 percent of those sitting in an appropriate child restraint. (Additionally, sitting in the front seat roughly doubles the risk of injury in all scenarios.)
Instead of further debating whether car seats are better than seat belts, we need to figure out how to use car seats better.
First, stricter laws are necessary since they legitimize the importance of car seats. According to Pediatrics, the greatest barrier to proper restraint use is ''the lack of concordance between state laws and best practice recommendations." In a 2002 study of reasons parents gave for not using booster seats, one commented, ''If it was important, there would be a law."
Second, installing car seats should be made easier. It took the National Highway Traffic Safety Administration 345 pages to explain proper installation, and certifying firefighters and others as ''child passenger safety technicians" requires a 4-day course.
Dr. Pratik Pradhan, a Harvard-educated surgeon from Westwood, couldn't decipher the instructions accompanying his son's infant car seat. He finally sought help from a local fire department, where a certified safety technician explained he hadn't tightened the straps holding the car seat down. According to a 2000 Archives of Pediatrics and Adolescent Medicine study, parents incorrectly install 93 percent of infant car seats, and of these, 80 percent make the same mistake as Pradhan. The two other common errors are not strapping the child in tightly enough (45 percent of the time) and not placing the harness retainer clip at armpit level (33 percent of the time).
Perhaps hospitals should help befuddled parents. After my son's birth, Brigham and Women's Hospital made me bring a car seat to the nursery. No one, however, checked whether I installed it correctly for the drive home.
Finally, insurers should treat restraining devices like lifesaving medicines, and help pay for them. According to a 1997 study in the American Journal of Public Health, giving away or greatly discounting car seats increased use from 4 percent of families to 80 percent in some urban areas. Most insurers, like Medicaid, cover asthma medications; why should they not also cover car seats, since accidents kill more kids than asthma?
For now, parents should remember three things: Young kids should always use some restraints no matter how short the trip; sit in the back seat; and correctly use a car or booster seat until old enough. When desperate, though, a seat belt is always better than nothing.
Dr. Darshak Sanghavi, an
assistant professor of pediatrics at UMass Medical School, can be reached
at www.darshaksanghavi.com. 
