Child Passenger Restraint Use Research Articles

Urban and Rural Child Deaths from Motor Vehicle Crashes: United States, 2015-2019

The objective of the study was to examine child deaths in motor vehicle crashes by rurality, restraint use, and state child passenger restraint laws. 2015-2019 Fatality Analysis Reporting System data were analyzed to determine deaths and rates by passenger and crash characteristics. Optimal restraint use was defined using age and the type of the restraint according to child passenger safety recommendations. Death rates per 100 000 population were highest for non-Hispanic Black (1.96; [1.84, 2.07]) and American Indian or Alaska Native children (2.67; [2.14, 3.20]) and lowest for Asian or Pacific Islander children (0.57; [0.47, 0.67]). Death rates increased with rurality with the lowest rate (0.88; [0.84, 0.92]) in the most urban counties and the highest rate (4.47; [3.88, 5.06]) in the most rural counties. Children who were not optimally restrained had higher deaths rates than optimally restrained children (0.84; [0.81, 0.87] vs 0.44; [0.42, 0.46], respectively). The death rate was higher in counties where states only required child passenger restraint use for passengers aged ≤6years (1.64; [1.50, 1.78]) than that in those requiring child passenger restraint use for passengers aged ≤7 or ≤8 years (1.06; [1.01, 1.12]). Proper restraint use and extending the ages covered by child passenger restraint laws reduce the risk for child crash deaths. Additionally, racial and geographic disparities in crash deaths were identified, especially among Black and Hispanic children in rural areas. Decision makers can consider extending the ages covered by child passenger restraint laws until at least age 9 to increase proper child restraint use and reduce crash injuries and deaths.

Child Passenger Helmet and Restraint Use: A Comparative Analysis From 10 Cities

Child Passenger Helmet and Restraint Use: A Comparative Analysis From 10 Cities

Child restraint use and hospital-reported injuries among crash-involved child passengers

Several states have enacted legislation addressing child passenger restraint use. In New Jersey (NJ), children <2 years are required to remain in rear-facing child restraints and passengers <4 year...

Prevalence of child passenger restraint use in Shantou, China from 2012 to 2017

BackgroundChild passenger safety is an important public health problem in China. This study aimed to examine the prevalence of child passenger restraint use while riding in a car in the city of Shantou in China from 2012 to 2017.MethodsThree large-scale cross-sectional observational studies were conducted in 2012, 2015 and 2017, respectively. The observation sites included randomly selected hospitals, kindergartens, and primary and secondary schools. The outcome measures included the changes in percentages of seating position (e.g., front vs. rear), whether sitting on lap, and use of child restraint systems (CRS) or seat belts by year and by age group. Descriptive statistics, Chi-square tests and logistic regression were used to address the study aims.ResultsA total of 9858 commuting children aged 17 and younger were observed in passenger cars in Shantou, China during the study. The proportion of children aged 0–5 sitting on adult’s lap decreased from 26.6% in 2012 to 24.6% in 2017, while the proportion of CRS use among the children sitting in the rear row increased among children aged 0–5 (from 0.7% in 2012 to 14.2% in 2017) and children aged 6–11 (from 0.7% in 2012 to 2.4% in 2017). Comparing children aged 0–11 in 2012, children in the same ages were less likely to sit in the front row in 2015 (OR = 0.42, 95%CI = 0.37, 0.48) and in 2017 (OR = 0.27, 95%CI = 0.23, 0.31). Children aged 0–11 were more likely to sit in the rear row with CRS use in 2015 (OR = 8.50, 95%CI = 5.44, 13.28) and in 2017 (OR = 10.95, 95%CI = 7.02, 17.08) comparing with children in the same ages in 2012. As for children aged 12–17, they were more likely to use seat belt in 2017 (OR = 1.40, 95%CI = 1.06, 1.85) compared with those children in 2012.ConclusionsWhile child passenger safety behaviors improved from 2012 to 2017 in Shantou, China, more efforts are needed to protect child passengers from injuries.

Discordance between age- and size-based criteria of child passenger restraint appropriateness

ABSTRACTObjectives: In this study, we sought to accomplish the following objectives: to (1) calculate the percentage of children considered appropriately restrained across 8 criteria of increasing restrictiveness; (2) examine agreement between age- and size-based appropriateness criteria; (3) assess for changes in the percentage of children considered appropriately restrained by the 8 criteria between 2011 (shortly after updates to U.S. guidelines) and 2015.Methods: Data from 2 cross-sectional surveys of 928 parents of children younger than 12 years old (n = 591 in 2011, n = 337 in 2015) were analyzed in 2017. Child age, weight, and height were measured at an emergency department visit and used to determine whether the parent-reported child passenger restraint was considered appropriate according to 8 criteria. Age-based criteria were derived from Michigan law and U.S. guidelines. Weight, height, and size-based criteria were derived from typical restraints available in the United States in 2007 and 2011. The percentage appropriate restraint use was calculated for each criterion. The kappa statistic was used to measure agreement between criteria. Change in appropriateness from 2011 to 2015 was assessed with chi-square statistics.Results: Percentage appropriate restraint use varied from a low of 19% for higher weight limits in 2011 to a high of 91% for Michigan law in 2015. Agreement between criteria was slight to moderate. The lowest kappa was for Michigan law and higher weight limits in 2011 (κ = 0.06) and highest for U.S. guidelines and lower weight limits in 2011 (κ = 0.60). Percentage appropriate restraint use was higher in 2015 than 2011 for the following criteria: U.S. guidelines (74 vs. 58%, P < .001), lower weight (57 vs. 47%, P = .005), higher weight (25 vs. 19%, P = .03), greater height (39 vs. 26%, P < .001), and greater size (42 vs. 30%, P = .001).Conclusions: The percentage of children considered to be using an appropriate restraint varied substantially across criteria. Aligning the definition of appropriate restraint use with current U.S. guidelines would increase consistency in reporting results from studies of child passenger safety in the United States. Potential explanations for the increased percentage of children considered appropriately restrained between 2011 and 2015 include adoption of the updated U.S. guidelines and the use of child passenger restraints with higher weight and height limits.

Dissemination of a Child Passenger Safety Program Through Trauma Center-Community Partnerships.

Improper child passenger restraint use contributes to higher pediatric motor vehicle collision morbidity and mortality among cultural minority populations. Child passenger safety education improves caregiver knowledge of restraint use, but effective interventions require culturally specific programming. The purpose of this study was to evaluate the effectiveness of a child passenger safety education program culturally adapted through a pediatric trauma center's community partnerships. A nonexperimental observational cohort study using program evaluation data for the child passenger safety education programs during a 24-month period. Paired pretest/posttest self-reported survey responses measured changes in caregiver knowledge and self-efficacy of restraint use. Data were analyzed by class location and by caregiver language using a paired t test and Wilcoxon's signed ranks test. A total of 1,795 paired survey responses were collected in English, Spanish, or Russian. An increase in mean knowledge scores occurred overall, with a difference in mean of 0.565 (SE = 0.022, 95% CI [0.521, 0.607]). Stratification by class site and by language reflected significant increases in median scores, but findings were variable by study group. Pretest median scores for self-efficacy of restraint use were high for all groups, but the increases in posttest medians were also significant across groups (p ≤ .001). Caregiver knowledge and self-efficacy for child passenger restraint use increased after participation in the community classes. The pediatric trauma center's community partnerships facilitated uptake and adaption of the child passenger safety education programs and increased the injury prevention outreach to minority communities.

A comparative analysis of child passenger restraint use in China and the United States.

Few published studies have examined child passenger safety practices across countries. This study compared the prevalence and associated factors of child passenger restraint use among children, aged 0 to 17 in the state of Iowa in the United States, and the city of Shantou in China. Child restraint use observations were conducted in Iowa and in Shantou in 2012, respectively, among child passengers. Observations in Iowa were conducted at randomly selected gas stations, while in Shantou observations were completed at randomly selected schools or medical clinics. Research observers approached the driver, observed restraint use, and collected brief survey data. A total of 3049 children from Iowa and 3333 children aged 0 to 17 years from Shantou were observed. For children aged 0 to 3 years, only 0.1% were compliantly restrained in Shantou as compared to 95.9% in Iowa. The proportion of children who were compliantly restrained in Shantou increased with age, but generally decreased with age in Iowa. In Shantou, 36.0% of children aged 0 to 3 were sitting in the front seat as compared to only 1.7% of children of the same age in Iowa. Driver seat belt use was significantly associated with child restraint in both Iowa and Shantou; the association was stronger in Iowa than Shantou for all age groups. A significantly higher prevalence of children who were not appropriately restrained was observed in Shantou than in Iowa. Our findings support the need of mandatory child safety restraint use legislation in China.

Reasons for Child Passenger Nonrestraint in Motor Vehicles

Objective: Although child passenger restraint use in motor vehicles has increased, there is an important minority of children who remain unrestrained. The goal of this study was to identify the frequency of and under what circumstances parents keep their children unrestrained.Methods: A cross-sectional, online survey was distributed to parents and caregivers of children 10 years old and younger. Survey participants were asked about child restraint practices, including frequency of and reasons for nonuse of restraints. Parents were specifically asked how acceptable it would be to keep their child unrestrained in certain situations.Results: One thousand two hundred eighty-five parents and guardians responded to the survey and 1,002 completed it; 23.8% (95% confidence interval [CI], 21.3–26.6%) of respondents said they had driven with their child not fully restrained on at least one occasion. Approximately 1 in 5 parents strongly or somewhat agreed that it would be acceptable to keep their child unrestrained in certain situations, including a short drive, in a rush, an inadequate number of restraints, riding in a taxi, if somebody was holding the child, and as a reward for a child. Parents were more likely to agree that it was acceptable to keep their child unrestrained under nearly all circumstances listed if they were male, ages 18–29, with a graduate school education, in the $100,000+ income bracket, or Latino.Conclusions: There are certain situations for which parents find it acceptable to leave their children unrestrained. This has implications for targeted child passenger safety efforts designed to maximize consistent restraint use.

0010 The safest R.I.D.E (restrained, in the back, day and night, every time)

<h3>Statement of purpose</h3> If in a crash, children under age 13 riding in the front seat are 50% more likely to be killed or seriously injured than children riding in the back seat (WA Traffic Safety Commission data). Washington law requires children under age 13 to ride in the back seat whenever practical to do so. Despite our strong child passenger safety laws and a well-developed statewide child passenger safety program, child passenger restraint use rates remain relatively low. This session demonstrates the use of observational data to create a focused educational and enforcement intervention at elementary schools to improve child passenger safety. <h3>Methods/Approach</h3> Observational surveys during morning drop-off at 16 elementary school showed approximately one in five children were illegally seated in the front seat. In partnership with law enforcement, four Safe Kids Coalitions conducted a four-week long educational and enforcement campaign at local schools. The Campaign included observational surveys, a letter home, classroom visits, media blasts, and campaign messaging at schools and in the community. A statewide parent survey was done by Safe Kids Washington to determine why children under age 13 were riding in the front seat. <h3>Results</h3> Results are coming in and will be shared at the Safe States Annual Meeting. <h3>Conclusions</h3> We are now in phase one. Early results show an improved rate of children riding in the back seat. The campaign will continue through June 2015. Results from phase one, including the parental survey data, will be used to inform phase two, which will have an added focus on booster seat use into 2016. <h3>Significance and contribution to the field</h3> Washington State has one of the strongest child passenger safety laws in the country. In our intervention development, we discovered few states have programs focused specifically on keeping children riding in the back seat, despite evidence that it reduces the rate of serious injury and death by half. Our approach of using state and local partnerships, research, data, education, and enforcement to help change risk behaviour is a good model for others to adapt or adopt in their community.

Roadside observation of child passenger restraint use

Background: Despite legislation and research evidence supporting the use of childhood vehicle restraints, motor vehicle crashes remain the leading cause of injury, death and disability among Canadian children. Methods: Working in collaboration with trained car seat specialists and police officers, roadside checks were conducted to observe correct use of child restraints. Results: Of the 1323 child vehicle restraints inspected, 99.6% of the children were restrained, 91% were in the correct seat, and 48% of restraints were correctly installed. The seat/restraint types most used incorrectly used were booster seats (31%) and seat belts (53%). The majority of incorrectly installed or fitted seats (55%) were forward facing. Common errors in installation and fit included the seat not being secured tightly enough to the vehicle, incorrect tether strap use, the harness not being tight enough, and/or the chest clip being in the wrong place. Conclusions: The greatest proportion of incorrect seat use was among those children who transitioned to a seat belt too soon. The greatest proportion of installation and fit errors were among forward facing seats. Researchers recommend: 1) targeting parents with older children (ages 3 and above) regarding transitioning too soon from forward facing seats to booster seats, and from booster seats to seat belts; 2) targeting parents with younger children regarding correct installation of rear facing and forward facing seats; 3) collaborating with police officers to review the most common errors and encourage observation at roadside checks; and 4) creating community awareness by way of roadside checks.

Disparities in Age-Appropriate Child Passenger Restraint Use Among Children Aged 1 to 12 Years

Observed racial disparities in child safety seat use have not accounted for socioeconomic factors. We hypothesized that racial differences in age-appropriate restraint use would be modified by socioeconomic status and child passenger safety information sources. A 2-site, cross-sectional tablet-based survey of parents seeking emergency care for their 1- to 12-year-old child was conducted between October 2011 and May 2012. Parents provided self-report of child passenger safety practices, demographic characteristics, and information sources. Direct observation of restraint use was conducted in a subset of children at emergency department discharge. Age-appropriate restraint use was defined by Michigan law. Of the 744 eligible parents, 669 agreed to participate and 601 provided complete responses to key variables. White parents reported higher use of car seats for 1- to 3-year-olds and booster seats for 4- to 7-year-olds compared with nonwhite parents. Regardless of race, <30% of 8- to 12-year-old children who were ≤4 feet, 9 inches tall used a booster seat. White parents had higher adjusted odds (3.86, 95% confidence interval 2.27-6.57) of reporting age-appropriate restraint use compared with nonwhite parents, controlling for education, income, information sources, and site. There was substantial agreement (82.6%, κ = 0.74) between parent report of their child's usual restraint and the observed restraint at emergency department discharge. Efforts should be directed at eliminating racial disparities in age-appropriate child passenger restraint use for children <8 years. Booster seat use, seat belt use, and rear seating represent opportunities to improve child passenger safety practices among older children.

Disparities in Age-Appropriate Child Passenger Restraint Use Among Children Aged 1 to 12 Years

Disparities in Age-Appropriate Child Passenger Restraint Use Among Children Aged 1 to 12 Years

Evaluation of a child passenger safety class in increasing parental knowledge

BackgroundChild passenger restraint systems have been found to greatly reduce the risk of injury and death among child passengers. However, nearly half of the children who died in 2009 as a result of motor vehicle crashes were completely unrestrained. Our global hypothesis is that parents and other caregivers failed to restrain children due to a lack of child passenger seat education and practice. In this report, we postulate that a car seat class will improve the basic understanding of child passenger safety. The objective of the study was to evaluate the effectiveness of a car seat class in increasing parental knowledge about child passenger safety. MethodsCar seat classes were held at a Level 1 pediatric trauma center every other Tuesday for ten months. The curriculum consisted of: child passenger safety laws discussion, a 21-min video on the use of child safety seats followed by a 15-min discussion about the video, 15min of discussing the different types of car seats, and hands-on training on how to properly install and use child restraints. Free car seats were provided to eligible parents. The pre-test was administered at the beginning of class and the post-test at the end of the class. McNemar's test and a paired t-test were used to compare pre- and post-test scores. Test scores were also stratified by language spoken. ResultsForty-four classes were held and a total of 491 parents/caregivers attended the classes. An increase in knowledge was found for all survey questions. Mean knowledge score for the post-test was 3.10 points higher compared to the mean knowledge score from the pre-test. Mean difference in knowledge scores for English-speaking participants were higher than Spanish-speaking participants. ConclusionLack of knowledge and low risk perception have frequently been cited as barriers for the use of child passenger restraints. Our intervention attempted to eliminate these barriers. We found that this intervention was effective at increasing parental knowledge about child passenger safety. The results of this study may be used to design and implement future interventions in multicultural settings.

Availability of Child Passenger Safety Resources to Emergency Physicians Practicing in Emergency Departments Within Pediatric, Adult, and Nontrauma Centers

More can be done to eliminate preventable motor vehicle collision (MVC)-related injuries through correct and consistent use of child passenger restraints. This study sought to determine emergency physician awareness of and referral patterns to child passenger safety resources and to compare awareness and referrals by practice setting. This was a cross-sectional mailed survey of a national random sample of 1200 emergency physicians drawn from the American Medical Association Physician Masterfile. Responses were returned by 638 (64%) of 1000 of physicians with a valid mailing address. Fifty-two percent reported working in an emergency department (ED) within a pediatric trauma center, 23% in an adult trauma center, and 25% in a nontrauma center. Police or fire department car seat installation programs were most frequently available (65% pediatric, 56% adult, 48% nontrauma center), and free/reduced-price booster seat programs least frequently available (46% pediatric, 30% adult, 23% nontrauma center) (P < 0.001). Half of pediatric trauma center physicians would always recommend replacement of a 3-year-old's car seat following a roll-over MVC compared with one third of adult and nontrauma center physicians (P < 0.001). There were no significant differences by practice setting for distribution of discharge instructions containing child passenger safety information or referrals to available resources. Availability of child passenger safety resources for children discharged from EDs following an MVC varies by practice setting. Pediatric injury prevention outreach to general EDs is needed to increase the number of children who are benefiting from existing community child passenger resources.

Child Passenger Restraints in Relation to Other Second-Row Passengers: An Analysis of the 2007–2009 National Survey of the Use of Booster Seats

Objective: Child restraint systems (CRS) are increasingly being designed to accommodate larger children and to mitigate side impact injuries. Little is known about the impact of CRS on the safety of other vehicle passengers due to limitations of existing crash databases. This study provides the first assessment of the seating positions occupied by child passengers and the relationship between CRS and other second-row passengers in a national sample of vehicles transporting children. Methods: A secondary analysis was conducted of data from the 2007–2009 National Survey of the Use of Booster Seats (NSUBS), a direct in-vehicle observational study of child passenger restraint use. Passengers riding in the same vehicle were identified and passenger position was determined. Vehicles with second-row child passengers were included in analyses of seat positions occupied by child passengers with and without CRS. Frequency counts for the different combinations of CRS and passengers in second rows were calculated. Results: Of the 17,065 vehicles observed in 2007–2009 NSUBS, 14,506 (85%) vehicles contained at least 1 child passenger in a second row that contained no more than 3 total passengers. Of these 14,506 vehicles, 55 percent contained a lone child passenger in the second row. A CRS was in use in 4656 (59%) of the 7949 vehicles with a lone child passenger in the second row compared to 4077 (62%) of the 6557 vehicles with multiple passengers in the second row (P < .001). A passenger was adjacent to a CRS within 1333 (33%) of the 4077 vehicles containing a CRS in the second row. There were 3 second-row passengers in nearly 1 in 5 vehicles containing a CRS in the second row. Conclusion: Adults and children not using CRS are frequently seated in vehicle second rows adjacent to a child restrained in a CRS. These findings should be used to inform the regulation, design, and testing of CRS and to determine the risks of larger CRS designs to other passengers seated in the same vehicle row relative to the benefits of the CRS for the passenger it restrains.

Trends and Correlates of Child Passenger Restraint Use in 6 Northwest Tribes: The Native Children Always Ride Safe (Native CARS) Project

We compared proportions of children properly restrained in vehicles in 6 Northwest American Indian tribes in 2003 and 2009, and evaluated risks for improper restraint. During spring 2009 we conducted a vehicle observation survey in Oregon, Washington, and Idaho tribal communities. We estimated the proportions of children riding properly restrained and evaluated correlates of improper restraint via log-binomial regression models for clustered data. We observed 1853 children aged 12 years and younger in 1207 vehicles; 49% rode properly restrained. More children aged 8 years and younger rode properly restrained in 2009 than 2003 (51% vs 29%; P < .001). Older booster seat-eligible children were least likely to ride properly restrained in 2009 (25%). American Indian children were more likely to ride improperly restrained than nonnative children in the same communities. Other risk factors included riding with an unrestrained or nonparent driver, riding where child passenger restraint laws were weaker than national guidelines, and taking a short trip. Although proper restraint has increased, it remains low. Tribe-initiated interventions to improve child passenger restraint use are under way.

Child Passenger Safety Practices in the U.S.: Disparities in Light of Updated Recommendations

Children are best protected in motor vehicle collisions when properly using the appropriate restraint and sitting in a rear row. Racial and ethnic disparities have been reported in injury statistics and use of any restraint; however, predictors of safety seat use, being unrestrained, and sitting in the front seat have not been explored previously.To determine factors associated with child passenger safety practices by race/ethnicity in a national sample of child passengers aged <13 years.Secondary analysis conducted in 2011 of the 2007, 2008, and 2009 National Survey of the Use of Booster Seats in which child passenger restraint use was observed directly. Age-stratified, survey-weighted chi-square and logistic regression analyses were conducted.Restraint use was observed for 21,476 children aged <13 years. A decline in child safety seat use and increase in being unrestrained were observed with increasing child age. In multivariate analyses, race/ethnicity, unrestrained drivers, and sitting in the front seat were associated with lower odds of child safety seat use among children aged <8 years. Older child age was associated with sitting in the front seat and being unrestrained. The presence of multiple child passengers was associated with lower odds of sitting in the front but higher odds of being unrestrained.Few children use the recommended child passenger restraints. Understanding the reasons for the suboptimal child passenger restraint practices identified in this study is essential for the development of effective programs to reduce or eliminate preventable motor vehicle collision-related injuries.

Grandparents and child passenger safety

PurposeThis study compares child passenger safety (CPS) practices of grandparents versus parents and determines grandparents’ opinions on car safety seats (CSS), barriers to use, and ways to transport grandchildren safely. MethodsObservational surveys were conducted on a convenience sample of drivers transporting children younger than sixteen years at 25 locations by certified child passenger safety technicians observing children in motor vehicles and recorded use of child passenger restraints. The drivers were surveyed on their knowledge, attitudes, beliefs, and practices regarding CPS. Data from drivers identifying themselves as grandparents were analyzed; also, three grandparent focus groups provided opinions on CPS practices. ResultsDuring the study 1758 parents transporting 2713 children and 284 grandparents transporting 391 grandchildren were included. While most drivers were restrained and used child occupant restraints, almost 25% of parents and grandparents chose the incorrect seat to transport the child, and greater than 68% had at least one harness error. Grandparents were more likely to have looser lower anchor straps or seat belts and have children younger than thirteen years in the front seat.The focus group-grandparents had a favorable attitude toward CSS. Grandparents acknowledged the need for CSS but opined that CSS were difficult to use. Physical barriers included arthritis, back pain, mobility, decreased strength, and vision problems. ConclusionsGrandparents and parents were equally likely to use CSS and choose correct seats. Compared to parents, grandparents were more likely to travel with their grandchildren with CSS installed with looser harnesses or an installed CSS with looser seat belt or lower anchors. Additionally, grandparents were more likely to have a child younger than thirteen years in the front seat. The use of community resources such as permanent fitting stations could help grandparents improve a grandchild's travel safety.

Restraint Use Law Enforcement Intervention in Latino Communities

Motor vehicle crashes are the leading cause of death for U.S. Latinos aged 1 to 35 years. Restraint use is an effective means of prevention of motor vehicle crash injury. Effective interventions to raise restraint use include the following: legislation, law enforcement, education, and equipment distribution. The effects of law enforcement interventions in Latino immigrant communities are understudied. We measured the community-level effect of a combined intervention that included warnings and citations phase enforcement in Latino communities. We designed and implemented in two of three Latino-majority communities a multicomponent intervention consisting of a community awareness campaign, restraint use education with equipment distribution, and a two-staged law enforcement intervention. Restraint use observations were conducted in all three communities at baseline, after the warnings phase and again after the citations phase of the intervention were completed. The combined intervention of community awareness, education, child passenger restraint distribution, and law enforcement focused on educational traffic stops with incentives and warnings was associated with a significant increase in both driver and child passenger restraint use in one intervention community, but only driver restraint increased to a level of significance in the other intervention community; significant increase was also noted among nonintervention drivers. The citations phase of the intervention did not result in a significant increase in restraint use and was complicated by interruptions due to unlicensed drivers. The combined effort of community awareness, education, equipment distribution and law enforcement intervention that included incentives and warnings may be effective at increasing seat belt use in Latino communities without the need for citations.

Restraint use and seating position among child car passengers: An observational study in Shanghai

Child passenger restraint practices in China are poorly characterized and few direct observational studies have been performed. This study aims to describe child passenger restraint use and to investigate factors influencing the restraint practices. A cross-sectional observational study was conducted at toll-gates in Shanghai during an 11-day period in June in 2009. A pro-forma observation checklist was used to collect data related to restraint use by child passengers aged ≤12 years, restraint use by drivers, and the number of child passengers traveling in passenger cars registered in Shanghai. Adjusted risk ratios (RR) comparing those children who were properly rear seated with those in other positions (front seat, on adult's lap) and any restraint use with no restraint use were evaluated using multivariate binomial regression with robust variance estimation. Among 967 children observed, 44.1% of children were in suboptimal seating positions (i.e., 12.2% in the front seat and 31.9% in adult laps) and 93.9% were unrestrained. Children aged ≤4 years (RR: 0.35, 95% Confidence Interval: 0.28–0.44), and those who were the only child in a car (RR: 0.84, 95% confidence interval: 0.74–0.96) had a lower likelihood of being properly rear seated. Children traveling with unrestrained drivers (RR: 0.09, 95% confidence interval: 0.01–0.60) were less likely to be restrained. This study demonstrates low restraint use and common suboptimal seating positions for child passengers in China and relates these to driver restraint use. These findings support the need for targeted programs to improve child restraint practices in China.