Research In Action

Despite decades of progress, motor vehicle crashes remain one of the leading causes of preventable injury and death among children worldwide. In this review, I examine why children continue to be seriously injured or killed as motor vehicle passengers, and what evidence tells us works to prevent these outcomes.

The science is clear: child restraint systems (CRSs) save lives when they are selected, installed, and used correctly. Yet misuse and non-use remain alarmingly common, contributing to a substantial proportion of child passenger fatalities. Children who are prematurely transitioned to forward-facing seats, boosters, or adult seat belts face dramatically higher injury risks, and incorrect CRS installation (which is consistently seen in up to 85% of cases) undermines the protective benefit of even the best-designed systems.

Persistent Inequities in Child Passenger Safety

A central theme of this review is inequity. Disparities in CRS access, knowledge, and adherence persist across and within countries, disproportionately affecting children from low-income households, rural communities, and marginalized populations. While high-income countries have reduced child passenger fatalities through legislation and safety programs, these gains are uneven, and global progress remains slow in low- and middle-income settings where enforcement, infrastructure, and affordable restraints are limited.

Even in the United States, where motor vehicle crashes remain the leading cause of injury-related death for children under 14, nearly 40% of children who die in crashes are unrestrained. These statistics underscore the need to address not only individual behavior but also systemic barriers to safety.

Evidence-Based Strategies That Work

The review highlights several interventions with strong evidence for improving child passenger safety:

• Legislation and enforcement: Well-designed, strictly enforced child restraint laws consistently improve compliance and reduce fatalities.
• Education and community engagement: Public awareness campaigns, culturally tailored education, and hands-on training (particularly through certified child passenger safety technicians) reduce misuse and improve caregiver confidence.
• Clinical integration: Pediatric clinicians are uniquely positioned to deliver anticipatory guidance. Electronic health record-based clinical decision support can standardize counseling, prompt age- and size-appropriate recommendations, and connect families to local resources.
• Access and affordability: CRS distribution programs, virtual inspections, and community-based partnerships are essential to closing equity gaps.

Expanding the Scope of Child Passenger Safety

Child passenger safety extends beyond traditional private vehicles. The review addresses emerging and underrecognized risks, including:

• Low CRS use in ride-share and taxi vehicles
• Unsafe practices on commercial flights
• Special transport needs for children with disabilities
• Non-crash injuries such as hot-car deaths and back-over incidents
• The misuse of car seats outside the vehicle

Looking ahead, autonomous vehicles and non-traditional seating configurations introduce new and largely untested challenges. These advances demand proactive collaboration among policymakers, vehicle manufacturers, CRS designers, clinicians, and researchers to ensure children remain protected in evolving transportation systems.

A Call to Action for Stakeholders

This review is ultimately a call to action. Preventing child passenger injuries and deaths requires sustained, cross-sector collaboration:

• Clinicians must prioritize child passenger safety counseling, advocate for equity-focused policies, and leverage health systems to normalize best practices.
• Policymakers must strengthen and enforce CRS laws and fund education and access initiatives.
• Community leaders and organizations must help reach families most at risk.
• Researchers and industry partners must continue innovating to meet emerging transportation challenges.

Ensuring that every child is properly restrained on every trip is an achievable goal. We already have the necessary, evidence-based tools. What remains is our collective commitment to apply them equitably, consistently, and without exception.