Risk Factors for Child Passengers

Key points

  • In 2021, 711 child passengers ages 12 and younger were killed in motor vehicle crashes in the United States, and in 2020 more than 63,000 were injured.

Who's at risk

Age

Restraint use (like car seat, booster seat, or seat belt use) varies by age.

  • Restraint use typically decreases as children get older.12345
    • In a study from 2021 where researchers observed children riding in cars, they found:
      • <1% of children under age 1 were not buckled up,
      • 6% of children 1–3 years old were not buckled up,
      • 11% of children 4–7 years old were not buckled up, and
      • 13% of children 8–12 years old were not buckled up.2
    • From a study using fatal crash data, researchers found:
      • 30% of 0–3-year-olds killed in crashes were not buckled up and
      • 36%A of 8–12-year-olds killed in crashes were not buckled up.1
  • Also, among children who are buckled up in child restraints, many graduate too soon to the next stage of child passenger safety. An example is when children stop using a booster seat before the seat belt fits them correctly. Age-appropriate restraint use typically decreases as children get older.67

Race and ethnicity

American Indian and Alaska Native children and Black children are more likely to be killed in a crash than White children.89

  • Child passenger death rates were highest among American Indian and Alaska Native children (2.67 per 100,000 population), followed by Black children (1.96), according to combined data from 2015–2019.9

Several studies also indicate that it is more common for Black children,2346810 Hispanic children,2481011 and American Indian and Alaska Native children10 to travel unrestrained or improperly restrained when compared with White children.

  • 21% of Black children, 15% of Hispanic children, and 7% of White children ages 4–7 years were not buckled up, according to a study in 2021 where researchers observed children riding in cars.2

There are likely many reasons for these differences, including access to affordable car seats and booster seats and differences in culture and perceptions related to car seat and booster seat use.

Places with increased risk

Rural versus urban location

Children in rural areas are typically at higher risk of being killed in a crash. According to combined data from 2015–2019:9

  • Child passenger death rates were highest in the most rural counties (4.5 per 100,000 population) and lowest in the most urban counties (0.9).9
  • Death rates among children who were not using age-appropriate restraints were highest in the most rural counties (2.9 per 100,000 population) and lowest in the most urban counties (0.5).9

Studies also indicate that children in rural areas are more likely to be incorrectly restrained than children in urban areas.712

  • A multistate study using data from car seat check events found that child restraint misuse was more common in rural locations (91%) than in urban locations (83%).12 Similar to racial and ethnic disparities, there are likely several factors for these differences.

Risk factors

Unrestrained drivers

Restraint use among children is associated with their driver's seat belt use.14567131415161718

  • In 2021, 69%B of child passengers ages 14 and younger killed in crashes who rode with unbuckled drivers were also not buckled up, compared with 26% of children riding with buckled drivers.1
  • Researchers who observed adults and children riding in cars in 2021 found that 95% of children ages 7 and younger who were driven by a buckled driver were restrained, compared with 77% of children driven by an unbuckled driver.14
  • Many other studies assessing different child age groups or specific geographic locations have also found strong associations between unrestrained drivers and unrestrained child passengers.45713151617

Car seat and booster seat misuse

Car seats and booster seats are often used incorrectly, which can make them less effective.

  • Researchers who observed children riding in cars in a 2011 study estimated that 46% of car seats and booster seats are used incorrectly in a way that could reduce their effectiveness.192021 Car seat misuse estimates are even higher at 59% when booster seats are excluded.19 The most common errors were:2021
    • Incorrect recline angle for rear-facing car seats
    • Loose installation for all car seats
    • Loose harness for all car seats
    • Harness behind child's arms, legs, or back in forward-facing car seats
    • Improper lap belt position for booster seats
    • Improper shoulder belt position for booster seats
  • Some smaller more recent studies indicate that misuse could be 85% or more in some areas.122223

Alcohol-impaired driving

Alcohol-impaired driving is a major threat to all road users, including child passengers.12425

  • In 2021, 25% of deaths among child passengers (ages 14 and younger) involved an alcohol-impaired driver.24
  • Among all child passengers (ages 14 and younger) who were killed in crashes, a higher proportion of those riding with alcohol-impaired drivers were unrestrained (43%)C compared with children riding with drivers who had no alcohol in their system (38%).1
  • Other studiesD have also found an association between driver alcohol use and child passengers being unrestrained.2513 For example, one study among children under 2 years old who were killed in crashes found that the odds of the child being unrestrained were 2.2 times higher when the driver had been drinking alcohol than when the driver had not been drinking.13
  1. Restraint status was known for 209 of the 242 child passenger vehicle occupants ages 8–12 who were killed in crashes in 2021. Among the 209 child passengers (ages 8–12) for which restraint status was known, 76 (36%) were unrestrained. Restraint status was known for 206 of the 223 child passenger vehicle occupants ages 0–3 who were killed in crashes in 2021. Among the 206 child passengers (ages 0–3) for which restraint status was known, 61 (30%) were unrestrained.
  2. These percentages are based on child passenger vehicle occupant and driver dyads for which restraint status was known.
  3. These percentages are based on child passenger vehicle occupants for which restraint status was known.
  4. The Quinlan et al. study assessed drivers with a BAC ≥0.08 g/dL. The Huang et al. study assessed drivers who tested positive for alcohol. About 22% of these drivers had a BAC lower than ≥0.08 g/dL.
  1. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2021 Data: Children (Report No DOT HS 813 456). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis; May 2023.
  2. Boyle L. The 2021 National Survey of the Use of Booster Seats (Report No. DOT HS 813 396). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); March 2023.
  3. Lee LK, Farrell CA, Mannix R. Restraint use in motor vehicle crash fatalities in children 0 year to 9 years old. J Trauma Acute Care Surg. 2015;79(3 Suppl 1):S55–S60. doi:10.1097/TA.0000000000000673
  4. Macy ML, Freed GL. Child passenger safety practices in the U.S.: disparities in light of updated recommendations. Am J Prev Med. 2012;43(3):272-281. doi:10.1016/j.amepre.2012.05.023
  5. Huang Y, Liu C, Pressley JC. Child Restraint Use and Driver Screening in Fatal Crashes Involving Drugs and Alcohol. Pediatrics. 2016;138(3):e20160319. doi:10.1542/peds.2016-0319
  6. Privette F, Nwosu A, Pope CN, Yang J, Pressley JC, Zhu M. Factors Associated With Child Restraint Use in Motor Vehicle Crashes. Clin Pediatr (Phila). 2018;57(12):1423–1431. doi:10.1177/0009922818786002
  7. Hamann CJ, Missikpode C, Peek-Asa C. Trends in pediatric passenger restraint use by rurality and age in Iowa, 2006–2019. Traffic Inj Prev. 2022;23(1):23–28. doi:10.1080/15389588.2021.1995603
  8. Sauber-Schatz EK, West BA, Bergen G. Vital Signs: Restraint Use and Motor Vehicle Occupant Death Rates Among Children Aged 0–12 years — United States, 2002–2011. MMWR Morb Mortal Wkly Rep. 2014;63(5):113–118.
  9. Shaw KM, West B, Kendi S, Zonfrillo MR, Sauber-Schatz E. Urban and rural child deaths from motor vehicle crashes: United States, 2015-2019. J Pediatr. 2022;S0022-3476(22)00620-5. doi:10.1016/j.jpeds.2022.07.001
  10. Lee SL, Yaghoubian A, Stark R, Munoz V, Kaji AH. Are there racial disparities in the use of restraints and outcomes in children after motor vehicle crashes?. J Pediatr Surg. 2012;47(6):1192-1195. doi:10.1016/j.jpedsurg.2012.03.022
  11. West BA, Yellman MA, Rudd RA. Use of child safety seats and booster seats in the United States: A comparison of parent/caregiver-reported and observed use estimates. J Safety Res. 2021;79:110–116. doi:10.1016/j.jsr.2021.08.011
  12. Hafner JW, Kok SJ, Wang H, Wren DL, Aitken ME, Miller BK, Anderson BL, Monroe KW. Child Passenger Restraint System Misuse in Rural Versus Urban Children: A Multisite Case-Control Study. Pediatr Emerg Care. 2017;33(10):663–669. doi:10.1097/PEC.0000000000000818
  13. Huang YY, Liu C, Pressley JC. Restraint use and injury in forward and rear-facing infants and toddlers involved in a fatal motor vehicle crash on a U. S. Roadway. Inj Epidemiol. 2019;6(Suppl 1):28. doi:10.1186/s40621-019-0200-4
  14. Boyle LL. Occupant Restraint Use in 2021: Results from the NOPUS Controlled Intersection Study (Report No. DOT HS 813 344). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); August 2022.
  15. Roehler DR, Elliott MR, Quinlan KP, Zonfrillo MR. Factors Associated With Unrestrained Young Passengers in Motor Vehicle Crashes. Pediatrics. 2019;143(3):e20182507. doi:10.1542/peds.2018-2507
  16. Missikpode C, Hamann CJ, Peek-Asa C. Association between driver and child passenger restraint: Analysis of community-based observational survey data from 2005 to 2019. J Safety Res. 2021;79:168–172. doi:10.1016/j.jsr.2021.08.016
  17. Oh SA, Liu C, Pressley JC. Fatal Pediatric Motor Vehicle Crashes on U.S. Native American Indian Lands Compared to Adjacent Non-Indian Lands: Restraint Use and Injury by Driver, Vehicle, Roadway and Crash Characteristics. Int J Environ Res Public Health. 2017;14(11):1287. doi:10.3390/ijerph14111287
  18. Benedetti M, Klinich KD, Manary MA, Flannagan CA. Predictors of restraint use among child occupants. Traffic Inj Prev. 2017;18(8):866–869. doi:10.1080/15389588.2017.1318209
  19. Greenwell NK. Traffic Safety Facts Research Note: National Child Restraint Use Special Study (Report No. DOT HS 812 157). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); June 2015.
  20. Greenwell NK. Results of the National Child Restraint Use Special Study (Report No. DOT HS 812 142). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); May 2015.
  21. Raymond P, Searcy S, Findley D. Traffic Safety Facts Research Note: Additional Analysis of National Child Restraint Use Special Study: Child Restraint Misuse (Report No. DOT HS 812 527) [PDF – 15 pages]. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA); July 2018.
  22. Bachman SL, Salzman GA, Burke RV, Arbogast H, Ruiz P, Upperman JS. Observed child restraint misuse in a large, urban community: Results from three years of inspection events. J Safety Res. 2016;56:17–22. doi:10.1016/j.jsr.2015.11.005
  23. Hoffman BD, Gallardo AR, Bridwell-Chapman M, Carlson KF. Unsafe from the Start: Serious Misuse of Car Safety Seats at Newborn Discharge. J Pediatr. 2016;171:48–54. doi:10.1016/j.jpeds.2015.11.047
  24. National Highway Traffic Safety Administration (NHTSA). Fatality and Injury Reporting System Tool (FIRST). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis; July 2023.
  25. Quinlan K, Shults RA, Rudd RA. Child passenger deaths involving alcohol-impaired drivers. Pediatrics. 2014;133(6):966–972. doi:10.1542/peds.2013-2318
  • Restraint status was known for 631 of the 711 child passenger vehicle occupants ages 12 and younger who were killed in crashes in 2021. Among the 631 child passengers for which restraint status was known, 226 (36%) were unrestrained.