Making the most of the worst-case scenario: Should belt-positioning booster seats be used in lap-belt-only seating positions?

November 2009

Objective: Examine real-world crash injury data to determine whether children seated with lap belts only are better protected with or without belt-positioning booster seats. Methods: Crash injury rates among booster-age children were examined for three restraint categories: lap belt only, belt-positioning booster seat with lap belt, and booster seat with lap/shoulder belt. Data were drawn from the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) and the Partners for Child Passenger Safety (PCPS) crash surveillance system for years 1997-2006 and 1998-2006, respectively. Main outcome measures were the percentage of crash-involved booster-age children with moderate or greater injury (maximum abbreviated injury score [MAIS] 2+). Results: The estimated risk of MAIS 2+ injury among children restrained with lap belts and boosters was 0.12 percent (NASS-CDS) and 0.96 percent (PCPS), compared with 1.21 and 1.74 percent, respectively, for lap belts only. This difference was not significant due to small numbers of children in lap belts with boosters. In PCPS, children restrained by lap/shoulder belts and boosters had lower injury risk than children restrained by lap belts, with or without boosters. Conclusions: Although data for children secured in lap belts with boosters are limited, the results suggest that boosters are not harmful. This finding is inconsistent with the current recommendation that booster seats not be used when children must be buckled with lap belts only. Data also confirm that booster seats with lap/shoulder belts remain the optimal protection for booster-age children.