If you scan the pavement on I-17 in Phoenix, just south of Carefree Highway, you might still see the white paint that marked where Marie Smith's Ford Explorer came to rest on November 11, 1999. The accident happened that morning as Smith was driving in a northbound lane with her two sons--6-year-old Dillon and 18-year-old Christopher. When the car in front of her braked suddenly, she swerved into the dirt on the right side of the road, then veered sharply to the left. The SUV tipped over, then rolled three or four times, blowing out windows and twisting the frame before it finally stopped, upside down, in the middle of the road.
By any account, it was a bad crash, but Smith had been prepared: Everyone had seat belts on, and Dillon was riding in the back, where safety experts say children are the most secure. Smith sustained fractures in her neck and arm, but her condition could have been much worse, and Christopher escaped with minor injuries. Dillon, however, was a different story. Evidence inside the vehicle suggested that his 49-pound body slipped out of his seat belt on the first roll and was tossed around. By the second roll, he was thrown out a broken window, landing on his face and shoulder. He fractured his skull in three places, broke his jaw, crushed his right eye socket, abraded his shoulder and knee to the bone, and broke his left thighbone. He lay in a coma for four days. Miraculously, Dillon survived. He is relearning to walk and back in school. "I can only attribute it to the glory of God," Smith says. "He should have died." Smith thought she had done all the right things. What happened? The answer came almost immediately, from paramedics on the scene. "They told me that a child his age should ride in a booster seat," Smith says. "I had taken a defensive-driving course two years before, and this was the first time I had ever heard anything like that. Putting Dillon in a seat belt met the requirements of the law, but that clearly wasn't good enough."
Among safety experts, it's a well-known fact that seat belts alone don't adequately protect kids who have outgrown car seats. Yet this message is not getting through to parents. "States typically no longer require children to be placed in car seats when they reach 4 years old or 40 pounds," says Carole S. Guzzetta, director of occupant-protection programs for the National Safety Council, in Itasca, Illinois. "Because of that, you assume it's okay to put a child in a seat belt. But most children will physically not be ready for a safety belt for another four to five years."
Organizations such as the National Safe Kids Campaign and the National Highway Traffic Safety Administration (NHTSA) are working to close what they see as shocking gaps in child-safety laws. Washington is currently the only state that has a booster-seat law; the legislation passed earlier this year and takes effect in July 2002. But safety advocates are also giving front-burner status to information campaigns aimed at parents. The critical point: Children should ride in booster seats from the moment they move out of child seats, at about age 4 or 40 pounds, until they weigh 80 pounds, usually between ages 8 and 10. It's an uphill battle on both fronts, given misperceptions about seat-belt safety that are alarmingly widespread.
Though studies find that 93 percent of parents put infants in safety seats, car-seat use drops dramatically as kids get older. According to the NHTSA, just 6 percent of 4-year-olds who have reached 40 pounds use booster seats; a recent study in Pediatrics shows that after age 5, booster usage drops to less than 1 percent. A recent survey commissioned by Parents magazine and the I Am Your Child Foundation found that almost three-quarters of parents say their kids stop using car seats or boosters between the ages of 4 and 6. Yet "premature graduation to seat belts is one of the foremost reasons for injury among restrained children in survivable crashes," says Flaura K. Winston, M.D., Ph.D., principal investigator at Partners for Child Passenger Safety, a research collaboration based at the Children's Hospital of Philadelphia. A new study by Dr. Winston shows that young children placed in seat belts rather than boosters or car seats are four times more likely to suffer head, brain, and other serious injuries.
To understand why booster seats are important, look at what happens when you strap lap and shoulder belts on a child who's too small for them. The first thing you notice is that the shoulder belt, designed to cross the chest of an adult, rides too high and brushes against her neck. Some parents fear that a misaligned shoulder belt could strangle a child in an accident, but crash tests find this is not the case. Instead, the real danger comes when the child inevitably shoves the shoulder belt under her arm or behind her back. "At that point, the child loses all upper-body protection," Dr. Winston says. "The torso and head are free to hit the knees or the back of the seat--we've even seen head injuries from hitting under the front of the seat, below knee level." Such violent upper-body movement can fracture the lumbar spine and injure the spinal cord.
The second hazard of poor belt fit may be even worse. "Kids have short legs, so they tend to slide forward to allow their knees to bend over the edge of the seat," says Dr. Winston. This makes the lap belt ride up on the abdomen, a position in which the child has essentially begun coming out of the seat belt. In a crash, a child sitting this way is at much greater risk of "submarining"--sliding all the way out of his restraint. But that's not all.
A belt that's positioned over the abdomen rather than the bony structures of the hips can be forced into the soft tissues of the belly, causing serious damage to the spleen, liver, kidneys, gastrointestinal tract, and other organs--a range of injuries known as seat-belt syndrome.
It doesn't take a highway rollover for an improperly positioned seat belt to cause life-threatening injuries. Cathy Lindhorst, of Blue Springs, Missouri, discovered this when her 17-year-old daughter was involved in an accident while driving her two younger brothers to school. A song had come on the radio that the girl thought inappropriate for her younger passenger, 8-year-old Patrick. While changing stations, she rammed the car in front of her at about 20 miles per hour. At first, everyone seemed okay. "But I teach at Patrick's school, and he came in that day crying that his stomach hurt," Lindhorst says. Their doctor could find no bruising or sensitivity to suggest internal injury, but when Patrick became lethargic after five days, Lindhorst took him to a hospital in Kansas City, Missouri, for exploratory surgery. Surgeons found that, on impact, the seat belt had pushed Patrick's stomach against his spine, which punctured part of the lower intestine and spilled bile and digestive juices throughout his body. "They told me that 80 percent of these kinds of injuries are fatal within 24 hours," Lindhorst says. Patrick was lucky: A successful surgery left his intestine completely healed.
Booster seats rearrange how a child lines up with a vehicle's lap and shoulder belts but generally don't contain their own straps or harnesses. "Boosters are really more of a positioning device than a restraint system," says Kathleen Weber, director of the Child Passenger Protection Research Program at the University of Michigan Medical School, in Ann Arbor. A child in a booster seat is lifted so the vehicle's shoulder belt crosses her chest properly, at the sternum and shoulder bones, and the lap belt rides low across the bones of the pelvis. This allows the strongest points of the upper body to resist the force of a crash, spreads the energy of the impact over a wider area, and drastically reduces the risk of internal injuries. What's more, the edge of a booster seat allows a child to bend his knees comfortably, encouraging him to sit straighter. Safety experts recommend two basic types of boosters: belt-positioning seats, which come in high-back and backless versions, and convertible high-backs, which function like car seats with harnesses for kids under 40 pounds and then convert to belt-positioning boosters as the children grow.
When Christine Guarino, of Germantown, Maryland, brought her van into a safety-seat checkpoint near her home, she had a convertible high-back for her 5-year-old son, Stephen, but was still restraining him with the harness attachment. The technician told her that because her son already weighed more than 40 pounds, he would be safer if she converted the seat to a belt-positioning booster so she could restrain him with a seat belt instead. The next day, a truck ran a stop sign and plowed into her while she was driving Stephen and his younger brother to their grandmother's. "The whole side of the van where Stephen was riding was ripped open like a can of sardines," she says. "But thankfully, he had no broken bones and no internal injuries. I'm convinced that the booster saved his life."
Now an NHTSA-certified checkpoint volunteer, Guarino inspects other families' cars and offers advice. "What I see in terms of booster seats," she says, "is a lot of nothing at all." Why don't more parents use them? "Partly, they feel that if it's not the law, it must not be very important," Guarino says. But when parents are honest, they offer other reasons as well: My child doesn't want to sit in a "baby" seat; nobody else uses them; the seats are inconvenient.
"We had a booster when Patrick was younger, but we got rid of it," Cathy Lindhorst admits. "Car seats are like bottles and diaper bags--things you want to be done with because you think it will make life easier. Safety never really crossed my mind." Now when she makes Patrick sit in a booster, Lindhorst feels little support from other families. "When I take him to Scouts, I have to embarrass him in front of everybody, because instead of letting him ride in somebody else's car, I drive him myself or make him take a booster along. It's a matter of doing what I know is right." 9/2000