• Britax Frontier

• Cosco Apex 65/ Safety 1st Alpha Elite Apex (or any combination of the above names as long as it contains the word “Apex”)

• A car seat with a 5-point harness for children AT LEAST 1 year of age who weigh 22-65 lbs.
• ALSO a high-back booster seat for children weighing 33-100lbs.
• Use of the tether is strongly recommended, but not required for kids using the 5-point harness.
• When using this seat (either as the car seat or the booster) the vehicle seat back MUST come up to at least the tops of the child’s ears. This restriction will limit the use of this seat as many older, lap-only belted vehicles have low seat backs.

• Nania Airway/ Legend SP

• A car seat with a 5 point harness for children AT LEAST 1 year of age who weigh 20-55 lbs
• AND a high-back booster for children weighing 33-80 lbs.
• Use of the tether is strongly recommended, but not required for kids using the 5 point harness.

• SafeGuard Go
  

• A car seat with a 5-point harness for children AT LEAST 1 year of age who are 34-52 inches tall and weigh 30-60 pounds.
• Top teather MUST be used.
• Also a backless booster for children at least 3 years old who weigh 40-100 pounds.
• When using seat in either mode, the vehicle's seat back MUST come up to at least the tops of the child's ears. This restriction will limit the use of this seat in older vehicles, since many seat positions with lap-only belts also have low seat back heights.
• Good for travel: It's lightweight (9lbs), folds into its own travel bag (included with seat), and installs very easily.

Forward-facing Only Car Seats

• Britax Super Elite/ Husky/ Regent

• Forward-facing only car seat for children AT LEAST 1 year of age who weigh 20-80 lbs.
• When using this seat for children weighing more than 50 pounds, you MUST use the top tether. When using this seat for children weighing less than 50 pounds, Britax strongly recommends using the tether as it will make the child safer (but it's optional).

• Fisher Price Futura
  

• Forward-facing only car seat for children AT LEAST 1 year of age who weigh 20-60 lbs.
• A top tether was available as an option for this seat (but was not required)
• Fisher Price stopped manufacturing this seat in 2001

• Ride Safer Travel Vest

• Use with lap-only belt for kids 35-60 lbs
• Use with shoulder/lap belt for kids 35-80 lbs
• Properly positions lap belt over child's hips
• Provides effective upper body restraint and head protection
• Properly positions shoulder belt across center of child's chest and between shoulder and neck
• Top tether prevents child's head and upper body from moving too far forward
• Available in two sizes: 35-60 lbs and 50-80 lbs

• Kid Y Harness with Ride Ryte Booster
  

• Fits kids 30-80 lbs when used with High-back Ride Ryte booster
• Fits kids 40-80 lbs when used with backless Ride Ryte booster
• Properly positions lap belt over child's hip bones using the arm rest guides on booster and the Kid Y harness
• Provides effective upper body restraint and head protection
• Tether connects Kid Y Harness to back of vehicle, preventing child's head and upper body from moving too far forward
• High-back boostger provides whiplash protection in vehicles with low seat backs
• High-back Ride Ryte booster easily converts to backless booster by simply detaching from base of booster

PLEASE NOTE: Ride Ryte MUST be used with Kid Y harness if vehicle seat has lap-only belt. Additionally, Ride Ryte can be used as a backless booster only if vehicle seat comes up to top of child's ears. Depending on the maximum weight capacity of the tether anchor in your vehicle, you may need to install a heavy-duty tether anchor.

Britax Laptop

• Fits children 30-65 lbs
• Vehicle seat MUST come up to at least top of child's ears
• No longer manufactured

PLEASE NOTE: This seat functions very differently than does a shield booster and should not be mistaken for one (shield boosters are not recommended.)

A Parent's Guide To Talking to Kids About Boosters

As parents, we must pick our battles. Allowing a child to skip her vegetables one night, or go outside without a coat will not cause harm. Riding without a booster seat could kill or seriously injure a child. Safety must be non-negotiable.

Nonetheless, riding in a booster seat should not be seen as a punishment. Involve your child in buckling up and explain to her how the booster seat works to keep her safe. Kids are much more likely to want to ride in a booster if they understand how it works, rather than “because Mommy and Daddy say I have to.”

Here are some easy ways to talk to your 4-10 year-old child about booster seats. The goal of this exercise is to show the child how they fit differently in the vehicle and in the safety belt when they sit on a booster compared to when they are not on a booster. (You can also watch the video in the Just For Kids section with your child.)

1. Have the child point to his shoulder bone (clavicle), chest bone (sternum) and hip bones (pelvis), which are the strong bones where the safety belt needs to rest. Ask the child what the bone feels like – he will typically say it feels hard/ like a rock/ strong/ etc.
2. Now have your child point to his belly (abdomen) and ask him what this feels like – he will typically say that it is squishy/ feels like a banana/ feels like jello/ etc. Especially for older children, you can explain what is in the abdomen – kidneys, liver, spleen, intestines, stomach, bladder, and the lower spinal cord. If you have an aspiring doctor, you could get an anatomy diagram and show them.
3. Ask your child to imagine that you are driving down the road and a puppy runs out into the street. Ask the child what the driver should do – most kids will volunteer “the driver will slam on the brakes.” Ask the child to recall how the safety belt suddenly feels very tight when the driver slams on the brakes (if the child can not recall this, you can buckle the child in and hold the shoulder belt tight to simulate this.)
4. Ask your child where he thinks is the best place for the safety belt to get tight – on his hard, strong bones or on his squishy belly? Most children will understand that it's better for the belt to be tight on the bones. The child should now have a basic understanding that the safety belt gets tight to keep them safe and needs to stay on their bones, not their squishy tummy.

Now, take the child out to the vehicle and do the 5-Step-Test with them.

1. Does the child sit all the way back against the vehicle seat?
2. Do the child's knees bend comfortably at the edge of the vehicle seat? If your child has not slouched forward already, ask him to slouch until his knees bend over the edge. Show him that when he slouches the lap belt is on his squishy tummy.
3. Does the belt cross the shoulder between the neck and the arm? Have the child point to his shoulder bone and chest bone – make sure the belt is touching there. If the belt is rubbing the child’s neck, the child will be tempted to put it under his arm or behind his back. Show the child that when it is under his arm it is not on his chest or shoulder bone. When it is behind his back he can lean forward so that his chest touches his legs and his head can hit his knees or the seat in front of him.
4. Is the lap belt as low as possible, touching the thighs? Have the child touch the tops of his legs – make sure the belt is resting there. Have the child touch his belly button – the lap belt should be far away from the belly button.
5. Can the child stay seated like this for the entire trip? Some kids like to squirm and slouch no matter what – and will need to ride in a booster seat to help keep them sitting straight.

If you answered "no" to any of these questions, your child needs a booster seat to make both the shoulder belt and the lap belt fit right to keep him the safest. If your child needs a booster, repeat the 5-step-test with him sitting on the booster and show him how he sits differently on the vehicle seat and how the safety belt fits him properly now.

When talking to your child, remember to emphasize that by sitting on a booster she will have more fun because:

• She can see better out of the window
• She is more comfortable
• Her knees bend over the edge of the booster – she doesn't have to slouch
• The shoulder belt is properly positioned so it isn't irritating her neck
• She have a place to store small toys/crayons/drinks – many boosters have cup holders built in

• Pick your battles. Safety is a non-negotiable battle that you must win every time. Tell your child that the car will not start unless he is sitting on his booster – and stick to this (don’t turn the motor on until he is properly buckled.) If he unbuckles himself (or places the shoulder belt behind his back or under his arm or does anything else that's dangerous) during the trip, pull over at the first safe place you can find, and firmly (without yelling and or showing any emotion) tell him to sit in the booster and that the car will not move until he is rebuckled.

• Positive reinforcement: Buy a pack of stickers that your child would like – and everytime she sits in the booster reward her at the end of the trip with a sticker. Let her place the sticker on the booster, on herself, in a small notebook that stays in the car, a “booster chart” or any other place that will visually reward her. There are other types of positive reinforcement you can use – if your child has a favorite song she likes to sing, promise to sing it with her/play it for her after each car ride when she sits in the booster. (Do not use food as a reward).

Misuse Patterns: Booster Seats and Safety Belts

Children under 40 pounds receive better protection from a child restraint with a 5-point-harness than a booster seat.^1,2 Unfortunately, 29% of 3 year olds (who weigh less than 40 pounds) are inappropriately graduated to a booster seat.

The misuse rate for boosters is at least 20-28%^3,4 with improper routing of the vehicle belt being the most common problem.

Common Mistakes

• shoulder belt incorrectly positioned
• child inappropriate height/weight for booster
• lap-only belt used for booster
• vehicle seat belt routed incorrectly

The other biggest source of misuse is simply non-use – i.e. kids who should be in a booster using just a safety belt, or worse yet riding completely unrestrained.

• 73% of kids who NEED a booster seat to ride safely are NOT in boosters
• While 78% of 4 year olds use booster seats, the number drops to 65% of 5’s, 43% of 6’s, 21% of 7’s, and a measly 11% of 8-year-olds.
• The motor vehicle occupant death rate for 5 to 9 year olds has changed little in the past decade, while deaths among other child age groups have greatly decline. 63% of kids who died were unrestrained. The remaining 31% were largely inappropriately restrained using safety belts instead of boosters.⁵

Injury Patterns for Booster Aged Kids NOT USING Boosters

Booster aged children wearing a safety belt alone (no booster) suffer their most serious injuries to:

• the head (44%)
• lower extremities (18%)
• thorax (17%)
• pelvis/abdomen (12%)

The Head: The most common complaint from 4-8 year olds who are not riding in boosters is that the shoulder belt is rubbing their neck. In an attempt to make themselves comfortable, many children remove the shoulder belt – either by placing it under their arm or behind their back, or simply moving to a position with only a lap belt. It is in these scenarios – where the child has nothing holding their upper body – that head injuries are most common.

Without restraint, the upper body rotates around the lap belt in a “jackknife” motion, allowing the head to travel very far forward with a good chance of contacting hard structures in the vehicle, such as the back of the front seat or even the child’s knees. Typical injuries include concussions, cerebral contusions, subdural hematomas, intracerebral hemorrhage, as well as myriad facial injuries. When compared with children appropriately restrained in boosters, those inappropriately restrained were 1.6 times more likely to suffer facial fractures. 2-5 year olds restrained in safety belts were more than 4 times more likely to sustain a significant head injury when compared with their peers riding in child restraints (car seats and boosters.)

The Abdomen: The area approximately from the bottom of the ribs to the hip bones is likely to be injured when the lap belt rides up over the bony pelvis (hip bones), concentrating the crash forces over the soft abdomen. The risk for these injuries increases when a child slouches or misuses the shoulder belt. Slouching places the lap belt on the abdomen even before a crash. Without a shoulder belt across your chest and shoulder bones (when you ride with a lap-only belt, or place the shoulder belt behind the back or under the arm) your body will double over itself in a crash, but since you bend at your waist (near your belly button) instead of at your hip bones, the lap portion of the belt rides up over the hip bones and into the abdomen.

A large study on thousands of crashes found no cases of abdominal injuries among 4-to-8-year olds riding in boosters. Those 4-8 year olds who were suboptimally restrained - using a safety belt when they should have been using a booster - were more than 3 times more likely to suffer an abdominal organ injury than those optimally restrained (in a booster seat). The presence of bruises on the abdomen or flanks is strongly associated with underlying intra-abdominal injuries – specifically those to the spine, bowel, and bladder.

Four mechanisms for the lap belt riding up into the abdomen have been described in the literature, each with a different root cause and pattern of injuries. It should be noted that the 6 year old crash test dummy (Hybrid III) does not accurately represent the human pelvis-belt interaction as no submarining occurs, so much of this data comes from real-world crashes.

1. Presubmarining: This occurs when the child's lap belt is positioned incorrectly, over the abdomen before a crash. Usually this occurs because a child is slouching. Injuries depend on exact positioning of the lap belt; presubmarining causes hollow viscus injuries in the lower abdomen if the belt started off low, and lacerations of the solid organs if the belt started off higher on the abdomen.

2. Dynamic Submarining: This can occur even if a child attempts to wear the lap portion of the safety belt correctly, because the child's pelvis is relatively small, cartilaginous, and lacks the prominent anterior superior iliac spines of an adult’s which keep the lap portion in place during a crash. The child is simply too underdevelped to allow the belt and pelvis to interact properly during a crash, so the lap portion rides up into the abdomen, causing bruising low along the pelvic and organ injuries to the abdomen.

3. Jack-Knife Kinematic: When a child uses a lap-only belt, or places a shoulder belt behind their back or under their arm, the unrestrained upper torso jackknifes over the lap belt. This leads to lumbar spine injuries and abdominal injuries.

4. No Shoulder Belt Used: The shoulder portion of the belt exerts a vertical force on the inboard side (the side where the buckle is) of the lap belt which helps to prevent submarining.

Booster Seats help prevent submarining and jack-knifing by maintaining proper lap belt positioning.

• The booster raises up the child, giving him a shallower seating area so that he can sit comfortably without slouching (which would lead to improper belt placement).
• The booster is also contoured on the sides, so that the lap belt is encouraged to remain on the tops of the legs, not the abdomen.
• Finally, the booster increases the lap belt angle during the crash, keeping the restraining force directed inferiorly away from the abdomen (since the belt is parallel to the road by virtue of resting on the tops of the legs, rather than perpendicular to the road, as it would be if it rested incorrectly on the abdomen.)

The Spine/Neck: Spinal cord injuries can occur when both the shoulder and lap belt are used, but are more common when the lap belt is the only form of restraint. When the lap belt rides up over the pelvis, applying all of the forces to the spine and abdomen, the thoracolumbar (chest and back) spine is at risk for injury. Not using a shoulder belt (or placing it behind the back or under the arm) increases the loads (forces) in the lumbar spine by as much as 5 times.

Many parents worry that the shoulder belt rubbing the child’s neck might be dangerous – thinking it could lead to spinal cord injury or even decapitation in a crash. These fears are completely unfounded; there is little, if any, evidence in the literature of cervical spine (neck) injuries resulting from poor positioning of the shoulder belt near the child’s neck (in situation’s where the child’s head does not strike anything in the vehicle). A shoulder belt that touches the side of the neck is not likely to cause injury unless the belt is very loose. Cervical spine injuries may occur when no shoulder belt is used – as the child’s head and upper body will travel forward, making the head likely to strike the front vehicle seat or even the child’s knees.

Selected References: Booster Seats

Click on the PubMed ID (PMID) number after any citation to go to the abstract and (where available) a link to the full text.

A

Agran, P. F., Anderson, C. L., Winn, D. G. (1998) Factors Associated with Restraint Use of Children in Fatal Crashes, Pediatrics, Vol. 102, e39. PMID 9724687

Angulo-Vazquez V, De Santis JP. Booster seat or seat belt? Motor vehicle injuries and child restraint laws in preschool and early school-age children. J Spec Pediatr Nurs. 2005 Oct-Dec;10(4):183-90. PMID 16223377

Arbogast KB, Durbin DR, Kallan MJ, Menon RA, Lincoln AE, Winston FK. The role of restraint and seat position in pediatric facial fractures. J Trauma. 2002 Apr;52(4):693-8. PMID 11956385

Arbogast KB, Durbin DR, Kallan MJ, Winston FK. Evaluation of pediatric use patterns and performance of lap shoulder belt systems in the center rear. Annu Proc Assoc Adv Automot Med. 2004;48:57-72. PMID 15319117

Arbogast KB, Kallan MJ, Durbin DR. Effectiveness of high back and backless belt-positioning booster seats in side impact crashes. Annu Proc Assoc Adv Automot Med. 2005 Sep;49:193-206. PMID 16179149

Arbogast KB, Mong DA, Mari-Gowda S, et al. Evaluating pediatric abdominal injuries. In: Proceedings of the 19th International Technical Conference on the Enhanced Safety of Vehicles; 2005. Paper 05-0046.

Association for the Advancement of Automotive Medicine. Position Statement: Need for booster seats for children between age 4 and 10. September, 2003. Available http://www.carcrash.org/booster.pdf Accessed January 21, 2006.

B

Byard RW, Noblett H. Child booster seats and lethal seat belt injury. J Paediatr Child Health. 2004 Nov;40(11):639-41. PMID 15469535

C

Child safety. Too many are too small for a seatbelt. Child Health Alert. 2003 May;21:4. PMID 12772693

D

Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA. 2003 Jun 4;289(21):2835-40. PMID 12783914

Durbin DR, Kallan MJ, Winston FK. Trends in booster seat use among young children in crashes. Pediatrics. 2001 Dec;108(6):E109. PMID 11731636

Durbin DR, Runge J, Mackay M, Meissner U, Pedder J, Wodzin E, Yoganandan N. Booster seats for children: closing the gap between science and public policy in the United States. Traffic Inj Prev. 2003 Mar;4(1):5-8. PMID 14522655

E

Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Use of child booster seats in motor vehicles following a community campaign: a controlled trial. JAMA. 2003 Feb 19;289(7):879-84. PMID 12588272

Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Too small for a seatbelt: predictors of booster seat use by child passengers. Pediatrics. 2003 Apr;111(4 Pt 1):e323-7. PMID 12671146

Edgerton EA, Orzechowski KM, Eichelberger MR. Not all child safety seats are created equal: the potential dangers of shield booster seats. Pediatrics. 2004 Mar;113(3 Pt 1):e153-8. PMID 14993569

H

Hout M, Brown J, Bilston L. Effectiveness of high back belt positioning booster seats in side impacts. Traffic Inj Prev. 2005 Jun;6(2): 147-55. PMID 16019400

K

Klinch K, Burton R. Injur y patterns of older children in automotive accidents. Paper 933082, Society of Automotive Engineers; 1993.

Koschel MJ. Boosting booster seat use: use simple education to help properly restrain youngsters. Am J Nurs. 2004 Aug;104(8):13. PMID 15300016

L

Lee JW, Fitzgerald K, Ebel BE. Lessons for increasing awareness and use of booster seats in a Latino community. Inj Prev. 2003 Sep;9(3):268-9. PMID 12966019

Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin DR, Winston FK. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg. 2004;39(6):972–975. PMID: 15185237

M

Miller T, Zaloshnja E , Sheppard M. Are booster seats needed: comparing occupant outcomes ages 4-7 versus 8-13. Annu Proc Assoc Adv Automot Med. 2002; 46:249-59. PMID 12361511

Morris SD. Misuse of booster seats. Inj Prev. 2001 Sep;7(3):254. PMID 11565998

Morris SD, Arbogast KB, Durbin DR, Winston FK. Misuse of booster seats. Inj Prev. 2000 Dec;6(4):281-4. PMID 11144628

N

Nance ML, Lutz N, Arbogast KB, Cornejo RA, Kallan MJ, Winston FK, Durbin DR. Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes. Ann Surg. 2004 Jan;239(1):127-31. PMID 14685110

Newman KD, Bowman LM, Eichelberger MR, Gotschall CS, Taylor GA, Johnson DL, Thomas M. The lap belt complex: intestinal and lumbar spine injury in children. J Trauma. 1990 Sep;30(9):1133-8; discussion 1138-40. PMID 2213946

P

Pierce SE, Mundt MP, Peterson NM, Katcher ML. Improving awareness and use of booster seats in Head Start families. WMJ. 2005 Jan;104(1):46-51. PMID 15779725

R

Ramsey A, Simpson E, Rivara FP. Booster seat use and reasons for nonuse. Pediatrics. 2000 Aug;106(2):E20. PMID 10920176

Rivara FP, Bennett E, Crispin B, Kruger K, Ebel B, Sarewitz A. Booster seats for child passengers: lessons for increasing their use. Inj Prev. 2001 Sep;7(3):210-3. PMID 11565986

S

Safe Kids Worldwide. Facts about injuries to child occupants in motor vehicle crashes. 2005. Available http://www.usa.safekids.org/content_documents/CPS_Fact_Sheet_2006_MEDIA.pdf Accessed January 21, 2006

Sherwood C, Crandall J, Stevens S, Saggese J, Eichelberger M. Sled tests and CIREN data illustrating the benefits of booster seats. Int J Crashworthiness. 2005;10(4):351–357

Sherwood C, Kent R, Crandall J. Booster seats and the transition from child restraints to adult seat belts. Top Emerg Med, Vol. 28, No. 1, pp. 21-29.

Sherwood CP, Shaw CG, Van Rooij L, Kent RW, Crandall JR, Orzechowski KM, Eichelberger MR, Kallieris D. Prediction of cervical spine injury risk for the 6-year-old child in frontal crashes. Traffic Inj Prev. 2003 Sep;4(3):206-13. PMID14522645

Simpson EM, Moll EK, Kassam-Adams N, Miller GJ, Winston FK. Barriers to booster seat use and strategies to increase their use. Pediatrics. 2002 Oct;110(4):729-36. PMID 12359786

Sivit CJ, Taylor GA, Newman KD, Bulas DI, Gotschall CS, Wright CJ, Eichelberger MR. Safety-belt injuries in children with lap-belt ecchymosis: CT findings in 61 patients. AJR Am J Roentgenol. 1991 Jul;157(1):111-4. PMID 2048507

Slavik D. Cervical distraction injuries to children.Society of Automotive Engineers; 1997. Paper 973306

Smith P. Emergency nurse urges booster seat advocacy after encounter at traumatic crash scene. J Emerg Nurs. 2005 Apr;31(2):185-L7. PMID 15834388

Stepanski BM, Ray LU, Nichols L. Booster seats: a community based study of installation and use by parents and caregivers. Annu Proc Assoc Adv Automot Med. 2001;45:37-48. PMID 12214362

W

Weber K. Crash protection for child passengers: a review of best practice. UMTRI Research Review. 2000 July-Sept:31(3): 1-28.

Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children. Pediatrics. 2000 Jun;105(6):1179-83. PMID 10835054

Citations: Misuse Patterns for Booster Seats and Safety Belts

1. National Highway Traffic Safety Administration. Child passenger safety. Accessed January 18, 2006.
2. American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Accessed January 18, 2006.
3. Morris SD, Arbogast KB, Durbin DR, Winston FK. Misuse of booster seats. Inj Prev. 2000 Dec;6(4):281-4. PMID 11144628
4. Stepanski BM, Ray LU, Nichols L. Booster seats: a community based study of installation and use by parents and caregivers. Annu Proc Assoc Adv Automot Med. 2001;45:37-48. PMID 12214362
5. National Highway Traffic Safety Administration. Booster Seats. Accessed January 18, 2006.