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Motor-Vehicle Occupant Fatalities and Restraint Use Among Children Aged 4-8 Years United States, 1994-1998

In the United States, more children aged 4-8 years die as occupants in motor-vehicle--related crashes than from any other form of unintentional injury (1). To reduce the number of deaths and injuries caused by motor-vehicle--related trauma, child passengers in this age group should be restrained properly in a vehicle's back seat (2). To characterize fatalities, restraint use, and seating position among occupants aged 4-8 years involved in fatal crashes, CDC analyzed 1994-1998 data from the Fatality Analysis Reporting System (FARS), which is maintained by the National Highway Traffic Safety Administration (NHTSA). This report summarizes the results of that analysis, which indicate that during 1994-1998, little change occurred in the death rate, restraint use, and seating position among children aged 4-8 years killed in crashes.

Motor-vehicle occupants who died in crashes during 1994-1998 were included in the analysis of FARS data. FARS is a census of traffic crashes in which at least one occupant or nonmotorist (e.g., pedestrian) died within 30 days of a crash on a public road within the 50 states, District of Columbia, and Puerto Rico. FARS includes information about restraint use and seating position derived from police crash reports. Restraint use (e.g., seat belts, child-safety seats [CSSs], and belt-positioning booster seats) was reported as used or not used. Seating position was designated as front, back, other, or unknown. Injury death rates per 100,000 population were calculated using annual estimates from the Bureau of the Census.

During 1994-1998, 14,411 child occupants aged 4-8 years were involved in crashes where one or more fatalities occurred; of these, 2549 (17.7%) died. Approximately 500 child occupants died each year during the study period; the average annual age-specific death rate was 2.6 per 100,000 population (Table 1). In 1994, restraint use among fatally injured children was 35.2% (177 of 503); in 1998, restraint use was 38.1% (201 of 527). The proportion of fatally injured children seated in the back seat of a vehicle involved in a crash was 50.1% (252 of 503) in 1994 and 53.7% (283 of 527) in 1998.

Reported by: Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

During 1994-1998, child occupant death rates did not decrease, restraint use among fatally injured child occupants changed little, and the proportion of fatally injured children seated in the back seat of a motor vehicle involved in a crash remained fairly constant. Children aged 4-8 years represent a special population for motor-vehicle occupant protection. Having outgrown CSSs designed for younger passengers, children aged 4-8 years frequently sit unrestrained or are placed prematurely in adult seat belt systems. Public health and traffic safety organizations recommend that children in this age group be restrained properly in booster seats (3). This study found that nearly two thirds of fatally injured children were unrestrained at the time of the crash. Only 4%-6% of children aged 4-8 years used booster seats when riding in motor vehicles (4,5).

Belt-positioning booster seats raise a child so that the shoulder belt fits securely between the neck and arm and the lap belt lies low and flat across the upper thighs. Children do not fit in adult lap/shoulder belts without a booster seat until they are 58 inches tall and weigh 80 lbs (3,6). Children should ride in a booster seat from the time they graduate from their forward-facing CSS until approximately age 8 years or until they are tall enough for the knees to bend over the edge of the seat when the child's back is resting firmly against the seat back.

Despite recommendations for children to ride in the back seat whenever possible to reduce risk for injury in a crash, approximately one fourth of child passengers ride in the front seat (7). Riding in the back virtually eliminates injury risk from deployed front-seat passenger air bags and places the child in the safest part of the vehicle in the event of a crash. As of January 1, 2000, 35 children aged 4-8 years have died while seated in front of air bags. Of these children, 31 (89%) were either unrestrained or improperly restrained (8). Riding in the back seat is associated with at least a 30% reduction in the risk for fatal injury (9). Approximately half of those children in this study who were fatally injured were sitting in the back seat.

The 50 states, District of Columbia, and Puerto Rico have child-passenger safety laws; however, substantial gaps in coverage exist for child passengers aged 4-8 years. For example, in 19 states, children this age can ride unrestrained in the back seat of a motor vehicle. In most states, children as young as age 4 years may use an adult seat belt. No state requires the use of booster seats for children who have outgrown their CSSs (10). Three states have laws requiring that children be seated in the back seat of passenger vehicles. The ages of the children covered by these laws vary by state.

The findings in this study are subject to at least three limitations. First, police crash reports overestimate restraint use; therefore, restraint use may be lower for children in this age group. Second, vehicle miles traveled have increased during 1994-1998; consequently, improvements in fatality rates may be masked by increased exposure to travel. Finally, increases in restraint use and resulting changes in occupant fatalities may require many years of investigation before they become apparent.

Reducing fatalities among motor vehicle occupants aged 4-8 years will require finding effective strategies to promote booster seat use and placement of children in the back seat. Public health and traffic safety efforts should be accelerated to increase appropriate occupant protection among children aged 4-8 years as a primary means to reduce fatal motor-vehicle--related injuries. Efforts are under way by CDC and others to determine the best ways to encourage booster seat use and to increase the prevalence of properly restrained children riding in the back seat.


  1. National Center for Health Statistics. Annual mortality tapes. Hyattsville, Maryland: US Department of Health and Human Services, CDC, 1994-1998.
  2. National Transportation Safety Board. Safety recommendation. Washington, DC: National Transportation Safety Board, 1997.
  3. CDC. National Child Passenger Safety Week--February 14-20, 1999. MMWR 1999;48:83-4.
  4. Winston FK, Durbin DR, Bhatia E, Werner J, Sorenson W. Patterns of inappropriate restraint for children in crashes. Joint session organized by the European Vehicle Passive Safety Network, AAAM, and IRCOBI. London, England: Professional Engineering Publishing Limited, 1999.
  5. Decina LE, Knoebel KY. Child safety seat misuse patterns in four states. Accid Anal Prev 1997;29:125-32.
  6. American Academy of Pediatrics Committee on Injury and Poison Prevention. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 1996;97:761-2.
  7. Segui-Gomez M, Glass R, Graham JD. Where children sit in motor vehicles: a comparison of selected European and American cities. Injury Prevention 1998;4:98-102.
  8. National Highway Traffic Safety Administration. Special crash investigations monthly counts for airbag-related fatalities and seriously injured persons. Washington, DC: National Highway Traffic Safety Administration, 2000.
  9. Braver ER, Whitfield R, Ferguson SA. Seating positions and children's risk of dying in motor vehicle crashes. Injury Prevention 1998;4:181-7.
  10. Insurance Institute for Highway Safety. Child restraint, belt laws as of January 2000. Available at: . Accessed January 31, 2000.

Table 1

Table 1
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