Mod10 January 2015

Editor's Notes

• #2: The purpose of this module is to prepare you to assess whether belt-positioning booster seats and seat belts are being correctly used and teach caregivers about their proper use.  
• #3: As a result of this module, you will be able to: - Identify how booster seats protect children. - Differentiate between types of booster seats. - Install a booster seat. - Explain recommendations for children in seat belts. - Explain best practices about booster seats and seat belts to caregivers.
• #4: Reference TGpage 10-1. We use the term belt-positioning booster seat when working with caregivers. This helps to emphasize how lap-and-shoulder belts keep the booster seats in place and keep children safe. In this module, we will shorten the term to booster seats.   Let’s first address how booster seats work.   - Booster seats and seat belts continue to protect children in the back seat of vehicles. Children should be in the back seat when under age 13 because it is safer.   - Children should be in booster seats until they are big enough to fit properly in a seat belt. This is the best practice, however, you will see children being moved into a seat belt at much younger ages because the caregivers believe the children are ready.   - Some booster seats are not tightly installed (locked in place) in the vehicle as with car seats.   - Booster seats are held in place by the child’s weight and the vehicle’s lap-and-shoulder belt.   - These seats boost children up for correct seat belt fit.   - Some new booster seats have lower anchor connectors to hold the seat in place when the child is not present.   - According to a Children’s Hospital of Philadelphia study (CHOP, 2003), booster seats are more than twice as effective in reducing risk of injury when compared with seat belts alone.   - Skipping the booster seat step or “graduating” to a booster seat too early is common and unsafe.   [Children’s Hospital of Philadelphia (CHOP) conducted a study entitled “Belt-Positioning Booster Seats and Reduction of Injury Risk Among Children in Vehicle Crashes” (Durbin, D.R., Elliott, M., et al. JAMA, June 4, 2003). This study found that belt-positioning booster seats are 59 percent more effective in reducing risk of injury when compared with seat belts alone.]   Q. How do you think booster seats protect children?  
• #5: Booster seats protect children by increasing crash protection from injuries. Booster seats:   - Are a middle step between a car seat with a harness and a seat belt to protect children who are too large for a car seat and too small for just the seat belt.   - Raise and position a child so the vehicle’s lap-and-shoulder belt fit properly over the stronger parts of a child’s body.   - The booster seat keeps the lap belt from causing injury to a child's abdomen and keeps the shoulder belt in proper position to give the child upper body protection.   Children should be moved to a booster seat only when they have outgrown the height or weight limit of their forward-facing car seat. Many booster seats have weight ranges starting at 40 pounds and ending at much higher limits.  
• #6: Reference TGpage 10-2. The Booster Seat vs. Lap Belt video demonstrates a 6-year-old restrained in a booster seat vs. being restrained by a lap-belt-only seat belt.   Watch for the yellow line that traces the movement of the child’s head during the crash.   Note the exaggerated movement of the child’s head when restrained by just a lap belt and how much further forward it moves than the child restrained in the booster seat.   Take notes in your TG as you watch the video.    [Play the video a second time if needed for participants to see the differences between a crash with the child in a booster seat vs. being restrained by a lap-belt-only seat belt.]   This video demonstrates why booster seats should NOT be used with lap-belt-only seat belts. Serious head and/or internal injuries can result from excessive head movement and jackknifing over the lap belt.  
• #7: Reference TGpage 10-2. This next video, Booster Seat vs. Lap-and-Shoulder Belt, demonstrates the 6-year-old restrained in a booster seat vs. being restrained by a lap-and-shoulder belt.   Again, the yellow line traces the movement of the child’s head during the crash.   Note how much further forward the child’s head moves when restrained by the lap-and-shoulder belt in comparison to the child restrained by the booster seat.   Take notes in your TG as you watch the video.     [Play the video a second time if needed for participants to see the differences between a crash with the child in a booster seat vs. being restrained by a lap-and-shoulder seat belt.]   The booster seat keeps the lap belt from causing injury to a child's abdomen by keeping it low on the upper hips and thighs. It also keeps the shoulder belt in proper position to give the child upper body protection.   Booster seats should only be used with lap-and-shoulder belts. Serious head or internal injuries can result from excessive head movement and jackknifing over the lap belt.   Booster seats:   - Must NEVER be used with just a lap belt. - Are NEVER used on airplanes. - May fit children up to 80 or 100+ pounds or more depending on specific models.   ALWAYS consult the booster seat owner’s manual for the weight ranges and correct use of booster seats.
• #8: Reference TGpage 10-3. We have talked about why booster seats are important and how they provide protection for children. Let’s now review two types of booster seats: high-back and backless.   - High-back booster seats are recommended for vehicles that have a low seat back or do not have a head restraint. A low seat back does not offer any support for a child’s head.   - High-back booster seats provide head, neck, and back support for the child.   - When correctly positioned on a booster seat, vehicle seat belts fit over the shoulder and hips like an adult in a seat belt.   - Use only shoulder belt positioners provided with the booster seat.   - Some high-back booster seats can only be used with vehicle head restraints behind them.   - Some high-back booster seats can be used as backless booster seats by removing the back.  
• #9: When a child has outgrown the height or weight limits of the internal harness of a combination car seat, the harness can be stored after removal and the seat can be used as a high-back booster.   Caregivers must carefully follow the manufacturer instructions for changing the combination car seat to a booster seat. Some seats have bases that also need to be removed to use as a booster seat.
• #10: With a backless booster seat, the child uses the vehicle’s seat back or built-in head restraint for head, neck, and back support.   - Use only with a lap-and-shoulder belt in a vehicle seating position with head restraints.   - Most backless booster seats come with a shoulder belt positioner to adjust the shoulder belt height on the child.   - The child’s ears should NOT be above the back of the vehicle seat or top of head restraint.   If a child in a booster seat must ride in the front seat:   - The child must be correctly restrained in a booster seat using the vehicle’s lap-and-shoulder belt.   - The vehicle seat must be moved back as far as possible from the dashboard.   Q. What questions do you have about the types of booster seats?
• #11: Reference TGpage 10-4. This next video, Install a Booster Seat, will take you through 5 steps for correct installation.   Watch carefully for the installation steps. Take notes in your TG as you watch the video.     Even if the child is not present, booster seats should be secured in the vehicle at all times. When not buckled, the booster seat may become a projectile or object that can be tossed around the vehicle causing injury to vehicle occupants during a crash or sudden stop.   Some forward-facing combination seats may allow for connecting the child restraint to the vehicle using LATCH even when used as a booster seat. However, some high-back boosters can only be used with a seat belt.   Booster seat use may be a hard sell to the child, especially if the child was prematurely transitioned to a seat belt too early.    
• #12: This slide is NEW Reference TGpage 10-5. [Provide a high-back and backless booster seat for each set of partners.]   Now that we have learned the steps to install a booster seat, each of you will practice installing a high-back and backless booster seat with a partner.   Read the manufacturer’s instructions to see how lap-and-shoulder belts are supposed to be positioned over and around the child and booster seat.   Focus on these questions as you practice your installations.   - Is the booster seat flat on the back seat of the vehicle? - Are there vehicle seat shoulder belt guides? - Might the vehicle head restraint need to be adjusted? - Is the booster seat height adjustable?   [Give 5 minutes for this practice activity. Walk around and provide feedback on their installations.]      There are key questions to answer related to booster seats.  
• #13: Reference TGpage 10-5. [Review the key questions.]   Let’s now practice explaining how to install a booster seat to caregivers.   I will ask a question as though I am a caregiver. Your task is to come up with the answer. You can also build on each other’s answers.     [Ensure that the following ideas are discussed. Have participants write down the correct responses in their TGs.   Why is it important to use booster seats?   Answer: Increases crash protection from injuries.   Protects children who are too large for a car seat and too small for a seat belt.   Booster seats are more than twice as effective in reducing risk of injury when compared with seat belts alone.   When should a child move to a booster seat?   Answer: Children should move to a booster seat when they have reached the maximum weight or height limits of their forward-facing car seat.   Is there a weight and/or height requirement for a booster seat?   Answer: While there is not a specific weight (i.e. number of pounds) or height requirement, children should be moved to a belt-positioning booster seat only when they have outgrown the height or weight limit of their forward-facing car seat.   What is the proper placement of the lap-and-shoulder belt?   Answer: For a seat belt to fit, the lap belt must lie snugly across the upper thighs – NOT the stomach. The shoulder belt should lie snug across the shoulder and chest and NOT cross the neck or face.]   Q. What remaining questions do you have about booster seats and your role in explaining best practices to caregivers?
• #14: Reference TGpage 10-6. Seat belts can be used when a child is:   Tall enough to sit without slouching. Able to keep his or her back against the vehicle seat. Able to keep his or her knees naturally bent over the edge of the vehicle seat. Able to keep his or her feet flat on the floor.   The lap belt must lie snugly across the upper thighs – NOT the stomach. The shoulder belt should lie snug across the shoulder and chest and NOT cross the neck or face.   Children must stay in position for the entire ride.   Children should NEVER have the shoulder belt under their arm or behind their back. This can cause severe injuries in a crash. If the seat belt does not fit properly, the child should use a booster seat.   Children under 13 should ride in the back seat. If a child is in the front seat, the vehicle seat must be moved back as far as possible from the dashboard.   They should NOT lean or rest against air bags, including side air bags.  
• #15: This next video, Beyond Booster Seats, demonstrates proper seat belt fit.   Watch carefully for seat belt fit tips. Take notes in your TG as you watch the video.
• #16: Adults are important role models for the safe behavior of children.   With carpools, emphasize to caregivers that they should make certain that booster seats and seat belts are used correctly every time children ride in a vehicle.   While lap belts are not ideal, they are better than no protection at all!   Reference TG page 10-8. [This progress check can be facilitated as a small group or pairs activity.]   Let’s apply what you have learned about children and seat belts.   Examine each photograph to determine if the seat belt is fitted properly.   If not fitted properly, identify the errors along with the consequences for the child   [Give participants a couple minutes to identify the error in each photograph.   Display the photographs as you debrief the progress check. As you display each photograph, ask participants to identify the error and what they think the consequences might be for the child.   Make the following points if they do not come up in the discussion. Encourage participants to write down the correct answers in their TGs.]  
• #17: Photograph #1   Answer: Error: The child is too small and the shoulder belt is resting on the child’s neck.   Consequences: It may cause spinal and stomach injuries.
• #18: Photograph #2   Answer: Error: The belt is too loose because the child has a backpack on. The lap belt is also too high.     Consequences: It increases forward movement and decreases belt effectiveness. It also allows the child to slide out of the position that protects against crash forces and may cause spinal and stomach injuries.
• #19: Photograph #3   Answer: Error: The shoulder belt is under the child’s arm.   Consequences: It increases head and neck movement, applies force to the rib cage and can cause serious injury, and creates a habit that can continue in later life.    
• #20: Photograph #4   Answer: Error: The shoulder belt is behind the child’s back.   Consequences: This position prevents the shoulder-and-lap belt parts from working together well, affects the proper fit of the lap belt, and does NOT provide upper body protection.
• #21: Photograph #5   Answer: Error: The seat belt should NOT be shared.   Consequences. Testing has not been done on shared belts and occupants will collide.  
• #22: Reference TGpage 10-9. Seat Belt Syndrome (SBS) describes injuries that doctors see as a result of occupants wearing only a lap belt in collisions involving only the front of a vehicle. These injuries usually result when the occupant’s body folds in half over the lap belt during a collision.   When this happens, the lap belt applies extreme force along the occupant’s pelvis to the mid-section.   Securing only the waist without restraining the upper body can cause serious head and neck injuries after a head strike.   Injuries typically include:   - Severe stomach injuries. - Fractures of the lumbar spine. - Serious head and facial injuries.     
• #23: Reference TG page 10-10. There are key questions to answer related to seat belts.   Is the child: - Tall enough to sit without slouching? - Able to keep his or her knees naturally bent over the edge of the vehicle seat? - Able to sit all the way back against the vehicle seat? - Able to keep his or her feet flat on the floor?  
• #24: Is the child: - Sitting with the shoulder belt crossing the shoulder between the neck and the arm? - Sitting with the lap belt as low as possible, touching his or her thighs? - Able to stay seated this way for the whole trip? Explain and demonstrate best practices to caregivers.   Follow these guidelines for a proper seat belt fit.   The lap belt must lie snugly across the upper thighs – NOT the stomach.   The shoulder belt should lie snug across the shoulder and chest and NOT cross the neck or face.    
• #25: This slide is NEW Reference TG page 10-10.   [Conduct the following progress check as a large group activity.   Ask for two volunteers to do a role play – one to play the caregiver and other the CPS Technician.   Give participant a couple of minutes for the role play.]   Let’s practice responding to a scenario that you may encounter in the field.   The caregiver tells you the following:   My child has used a seat belt since he was 4 years old. What should I do now that he is 6 years old?   What is the proper seat belt use for this situation?   While you listen to the role play, write down ideas for how to respond to the situation in your TGs.   [Make the following points if they do not come up in the role-play.]   1. What is the proper seat belt use for this situation?   Answer: Most children under 8 are not big enough to use an adult seat belt.   2. When can a child move to a seat belt?   Answer: Seat belts can be used when a child is:   - Tall enough to sit without slouching. - Able to keep his or her back against the vehicle seat. - Able to keep his or her knees naturally bent over the edge of the vehicle seat. - Able to keep his or her feet flat on the floor.   Q. What remaining questions do you have about children in booster seats and seat belts and your role in explaining best practices to caregivers? The purpose of this module was to prepare you to assess whether belt-positioning booster seats and seat belts are being correctly used and to teach caregivers about their proper use. There is an additional topic to cover before we move on to more installation and communication activities – child passenger safety in other vehicles.