Background:​ Currently, many states are upgrading their child restraint laws to include provisions for the use of age-appropriate restraints through 6 to 8 years of age, with some also requiring rear seating for children, enabling the laws to be in closer alignment with best-practice recommendations.

Objective:​ To evaluate the relationships of seating position and restraint status to the risk of injury among children in passenger vehicle crashes.

Methods:​ This was a cross-sectional study of children <16 years of age who were involved in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 17980 children in 11506 crashes, representing 229106 children in 146613 crashes, was collected between December 1, 1998, and November 30, 2002. Parent reports were used to define restraint status, seating position, and occurrence of clinically significant injuries, with the use of a previously validated instrument.

Results:​ Approximately 62% of the children used seat belts, 35% used child restraints, and 3% used no restraint. Nearly 4 of 5 children sat in the rear seat, with one half of all children being restrained appropriately for their age in the rear, although this varied according to the age of the child. Overall, 1.6% of children suffered serious injuries, 13.5% had minor injuries, and 84.9% did not have any injury. Unrestrained children in the front were at the highest risk of injury and appropriately restrained children in the rear were at the lowest risk, for all age groups. Inappropriately restrained children were at nearly twice the risk of injury, compared with appropriately restrained children (odds ratio [OR]:​ 1.8;​ 95% confidence interval [CI]:​ 1.4–2.3), whereas unrestrained children were at >3 times the risk (OR:​ 3.2;​ 95% CI:​ 2.5–4.1). The effect of seating row was smaller than the effect of restraint status;​ children in the front seat were at 40% greater risk of injury, compared with children in the rear seat (OR:​ 1.4;​ 95% CI:​ 1.2–1.7). Had all children in the study population been appropriately restrained in the rear seat, 1014 serious injuries (95% CI:​ 675–1353 injuries) would have been prevented (with the assumption that restraint effectiveness does not depend on a variety of other driver-related, child-related, crash-related, vehicle-related, and environmental factors).

Conclusions:​ Age-appropriate restraint confers relatively more safety benefit than rear seating, but the 2 work synergistically to provide the best protection for children in crashes. These results support the current focus on age-appropriate restraint in recently upgraded state child restraint laws. However, it is important to note that considerable added benefit would be realized with additional requirements for rear seating.