Car Seat Safety

Car seat recommendations … Clear as mud!

One of the most common questions and discussions I have with patients and parents is about car seat recommendations. Obviously, we want our kids to be safe no matter where they are. However, even if we are the safest drivers in the world, some other driver might be drinking, texting, distracted or in a rush, putting us and our children at risk. Motor vehicle accidents are the number 1 cause of death for children ages 2-15 in the United States. Given these sobering statistics, what can we do?

The confusion about car seats comes not from whether we want to keep our kids safe,but from the different recommendations, laws, and types of seats available. Let’s see if I can help clarify it a little…


The American Academy of Pediatrics (AAP) recommends the following:

Infants and Toddlers: Infants and children under age 2 years should be in a rear-facing car seat. If possible keep children rear-facing until they have also reached the highest weight and height recommended by the car seat manufacturer.

Toddlers and Preschoolers: Children 2 years or older who have outgrown the rear-facing seat can sit in  a forward-facing car seat with a 5-point harness until at the maximum height and weight recommended by the car seat manufacturer.

School-aged Children: A belt-positioning booster seat should be used by children ages 5 and above until the vehicle seat belt fits properly; usually at a height of 4’9″ tall and between ages 8-12 years. Use the booster with a back until the child’s shoulders are at or above the level of the belt positioner/ harness slots.

Older children: Lap and shoulder belt should always be worn. All children younger than 13 years should sit in the back seat.


The recommendation for rear-facing seats until age 2 years started in 2010. It was based on some very good safety data in Philadelphia that showed a significant decrease in risk of injury for children less than 2 years when they were rear-facing; this was especially true for side-impact collisions. The study was not conducted for children older than 2.

Similarly, the continued use of booster seats for older children are based on data that show that improper seatbelt positioning (ie lap belt without shoulder belt, positioning the shoulder belt over the neck or face, or moving the shoulder belt behind the torso) actually increases the risk of severe abdominal injury during a collision. The booster seat is designed to lift a child to the height of an adult, so that the shoulder belt sits comfortably across the shoulder and will safely restrain without injury.

Ok, so WHY do they have to sit in the back seat until 13? They’re as BIG as you are, they are persistent about how mean you are and how all their friends sit up front, and, let’s face it, it’s nice to have company in the front seat. Here’s the scoop. While the 12 year old seems mature and large, their sternum (breast bone) and hip bones are not yet fully developed. They continue to grow, strengthen, and remodel through adolescence. So, the seatbelt that might appropriately restrain a 110 pound adult, will not safely restrain a child at the same weight. There is an increased risk of injury to abdominal organs, and the heart. Furthermore, children’s torsos typically lean forward during pre-crash braking. This forward motion toward the airbag as it is deploying can cause severe head and neck injuries. If you HAVE to put your child in the front seat, make sure to put the seat all the way back and turn off the front and side airbags.

Now that we know the safety recommendations and the reasons for them, what do the laws say? Each state has different laws about child safety restraints and seatbelts. Here’s what Massachusetts and New Hampshire have to say…


MA State Law Requires:

    1) Child restraint (5-point car seat) for all children until at least 5 years old and until they weigh more than 40 pounds.

    2) Booster seat for children 5-7 years old or until they are at least 4 feet 9 inches (57 inches or 145cm) tall.

    3) All drivers and passengers who are not in a child safety restraint must wear a seatbelt.

*Back seat for all children under age 13 is strongly recommended but not required


NH State Law Requires:

    1) Child restraint (5-point car seat) for all children until at least 5 years old and at least 55 inches in height.

    2) Children ages 6-17 MUST use a seatbelt.

* In NH, booster seats are recommended and a suggestion is made to have children less than 13 sit in the back seat, but this is not a requirement.


In sum, remember the tired old saying: “seatbelts save lives.” It’s true. Don’t risk your life or your child’s because the seatbelt is uncomfortable, un-”cool,” or you’re just going around the block.  Hang tough, stay strong, wear your own seatbelt, and your child will too!



Car Seat Handout

Car Seat Handout_spanish