Primary Care Approaches
Patricia L. Jackson Allen, MS, RN, PNP, FAAN

Booster Seat Usage for Children
4 to 8 Years of Age
Debbie Gearner Thompson, Brian Robertson

C

hild restraint devices have significantly decreased child injury and death rates as the result of motor vehicle crashes. Despite these devices, motor vehicle crashes remain the leading cause of death in children 4 years of age and older (Committee on Injury,
Violence, and Poison Prevention, American Academy of
Pediatrics [AAP], 2011). All 50 states and the District of
Columbia have child safety seat laws, but they vary from state to state regarding children’s ages and types of restraint
(Governor’s Highway Safety Association [GHSA], 2012).
Only Arizona, Florida, and South Dakota do not require booster seats or other devices for children who have outgrown their child safety seats but are still too small to safely use an adult seat belt.
Ages vary by state regarding when booster seats must be used. Although laws exist, the use of booster seats for young school-aged children has been consistently lower than national goals (Macy et al., 2012). Many parents are unaware of state laws regarding booster seat use (Macy et al., 2012) and believe that children over 4 years of age can be transitioned from traditional child car seats to using only a seat belt. Lack of awareness that booster seats are designed to reduce the risk of injury and death in the event of a collision by repositioning the child’s body so that the seat belt properly secures the child is also an issue for many parents (see Figure 1) (Arbogast, Jermakian, Kallan, &
Durbin, 2009; Bruce et al., 2009; Durbin, Elliott, &
Winston, 2003; Elliott, Kallan, Durbin, & Winston, 2006).
Elliott and colleagues (2006) evaluated the effectiveness of child safety seats vs. seat belts and found that children 2 to 6 years of age had a reduction in nonfatal injuries and a 28% reduction in risk of death using booster seats when compared to wearing only seat belts. The authors stress that the child restraint system is designed to reduce the risk of ejection and distribute the force of the crash through structurally stronger bones rather than soft tissues.
By limiting crash forces and potentially limiting the contact

of the occupant with the vehicle, a child restraint system provides a mechanical protection advantage over seat belts.
When children are transitioned to adult seat belts too early, the lap portion of the belt rides up over their abdomen, with the shoulder portion crossing the neck or face. The child may also sit too far forward in order for their knees to bend at the edge of the seat. Because of the inappropriate positioning of the seat belt, the 4- to 8-year-old child using the shoulder-lap belt only is three times more likely to sustain abdominal injuries than the child restrained in a booster seat (Partners for Child Passenger
Safety, 2004). During the rapid deceleration of a motor vehicle accident, a jack-knifed body position compresses the abdominal organs and the spinal column against the seat belt (Committee on Injury, Violence, and Poison
Prevention, AAP, 2011). This phenomenon, called “Seat
Belt Syndrome,” has been identified in cases involving serious cervical and lumbar spinal cord injury and intraabdominal injuries related to poorly fitting seat belts. These

Figure 1.
Proper Seat Belt Placement When Utilizing
Booster Seat

Lap belt rests on tops of thighs
Shoulder belt crosses center of chest bone and rests between shoulder and neck

Debbie Gearner Thompson, MS, RN, CNS, PNP-BC, is a Pediatric
Nurse Practitioner, Children’s Medical Center Legacy, and Certified
Car Seat Technician, National Child Passenger Safety Program,
Plano, TX.
Brian Robertson, PhD, MPH, is a Research Scientist, Injury
Prevention Department, Children’s Medical Center Dallas, and
Certified Car Seat Technician, National Child Passenger Safety
Program, Dallax, TX.

Child’s knees bend comfortably without touching

Note: Used with