Risk Factors for Child Passengers

Key points

  • In 2023, 1,019 child passengers ages 14 and younger were killed in motor vehicle crashes in the United States, and more than 161,000 were injured.
  • Parents and caregivers can make a lifesaving difference by ensuring that their children are properly buckled on every trip.

Who's at risk

Age

Restraint use (like car seat, booster seat, or seat belt use) varies by age.

  • Restraint use typically decreases as children get older.12345
    • In a study from 2023 where researchers observed children riding in cars, they found:
      • <4% of children under age 1 were not buckled up,
      • 6% of children 1–3 years old were not buckled up,
      • 13% of children 4–7 years old were not buckled up, and
      • 16% of children 8–12 years old were not buckled up.2
    • From a 2023 study using fatal crash data, researchers found:
      • 27% of 0–3-year-olds killed in crashes were not buckled up,
      • 37% of 4–7-year olds killed in crashes were not buckled up, and
      • 50%A of 8–12-year-olds killed in crashes were not buckled up.1
  • Also, among children who are buckled up in child restraints, many graduate too soon to the next stage of child passenger safety. An example is when children stop using a booster seat before the seat belt fits them correctly. Age-appropriate restraint use typically decreases as children get older.67

Race and ethnicity

American Indian and Alaska Native children and Black children are more likely to be killed in a crash.89

  • In 2022, motor vehicle occupant death rates among children ages 14 and younger were highest among American Indian and Alaska Native children (6.2 per 100,000 population), followed by Black children (2.4).10

Several studies also indicate that it is more common for Black children,2346811 Hispanic children,2481112 and American Indian and Alaska Native children11 to travel unrestrained or improperly restrained.

  • 21% of Black children, 15% of Hispanic children, and 7% of White children ages 4–7 years were not buckled up, according to a study in 2021 where researchers observed children riding in cars.2

There are likely many reasons for these differences, including access to affordable car seats and booster seats and differences in culture and perceptions related to car seat and booster seat use.

Places with increased risk

Rural versus urban location

Children in rural areas are typically at higher risk of being killed in a crash. According to combined data from 2015–2019:9

  • Child passenger death rates were highest in the most rural counties (4.5 per 100,000 population) and lowest in the most urban counties (0.9).9
  • Death rates among children who were not using age-appropriate restraints were highest in the most rural counties (2.9 per 100,000 population) and lowest in the most urban counties (0.5).9

Studies also indicate that children in rural areas are more likely to be incorrectly restrained than children in urban areas.713

  • A multistate study using data from car seat check events found that child restraint misuse was more common in rural locations (91%) than in urban locations (83%).13 Similar to racial and ethnic disparities, there are likely several factors for these differences.

Risk factors

Unrestrained drivers

Restraint use among children is associated with their driver's seat belt use.14567141516171819

  • In 2022, 68%B of child passengers ages 14 and younger killed in crashes who rode with unbuckled drivers were also not buckled up, compared with 27% of children riding with buckled drivers.1
  • Researchers who observed adults and children riding in cars in 2021 found that 95% of children ages 7 and younger who were driven by a buckled driver were restrained, compared with 77% of children driven by an unbuckled driver.15
  • Many other studies assessing different child age groups or specific geographic locations have also found strong associations between unrestrained drivers and unrestrained child passengers.45714161718

Car seat and booster seat misuse

Car seats and booster seats are often used incorrectly, which can make them less effective.

  • Researchers who observed children riding in cars in a 2011 study estimated that 46% of car seats and booster seats are used incorrectly in a way that could reduce their effectiveness.202122 Car seat misuse estimates are even higher at 59% when booster seats are excluded.20 The most common errors were:2122
    • Incorrect recline angle for rear-facing car seats
    • Loose installation for all car seats
    • Loose harness for all car seats
    • Harness behind child's arms, legs, or back in forward-facing car seats
    • Improper lap belt position for booster seats
    • Improper shoulder belt position for booster seats
  • Some smaller more recent studies indicate that misuse could be 85% or more in some areas.132324

Alcohol-impaired driving

Alcohol-impaired driving is a major threat to all road users, including child passengers.12526

  • In 2022, 25% of deaths among child passengers (ages 14 and younger) involved an alcohol-impaired driver.25
  • Among all child passengers (ages 14 and younger) who were killed in crashes, a higher proportion of those riding with alcohol-impaired drivers were unrestrained (50%)C compared with children riding with drivers who had no alcohol in their system (36%).1
  • Other studiesD have also found an association between driver alcohol use and child passengers being unrestrained.2614 For example, one study among children under 2 years old who were killed in crashes found that the odds of the child being unrestrained were 2.2 times higher when the driver had been drinking alcohol than when the driver had not been drinking.14
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Content Source:
National Center for Injury Prevention and Control
  1. Restraint status was known for 206 of the 226 child passenger vehicle occupants ages 8–12 who were killed in crashes in 2021. Among the 206 child passengers (ages 8–12) for which restraint status was known, 88 (43%) were unrestrained. Restraint status was known for 188 of the 202 child passenger vehicle occupants ages 0–3 who were killed in crashes in 2021. Among the 188 child passengers (ages 0–3) for which restraint status was known, 50 (27%) were unrestrained.
  2. These percentages are based on child passenger vehicle occupant and driver dyads for which restraint status was known.
  3. These percentages are based on child passenger vehicle occupants for which restraint status was known.
  4. The Quinlan et al. study assessed drivers with a BAC ≥0.08 g/dL. The Huang et al. study assessed drivers who tested positive for alcohol. About 22% of these drivers had a BAC lower than ≥0.08 g/dL.
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  18. Oh SA, Liu C, Pressley JC. Fatal Pediatric Motor Vehicle Crashes on U.S. Native American Indian Lands Compared to Adjacent Non-Indian Lands: Restraint Use and Injury by Driver, Vehicle, Roadway and Crash Characteristics. Int J Environ Res Public Health. 2017;14(11):1287. doi:10.3390/ijerph14111287
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