Evidence-based
Recommendations for Car Seat,
Booster Seat and Seat Belt Use for
Children
March 2023
2
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
©2023, Alberta Health Services, Provincial Injury Prevention
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Contact
For more information, please contact:
Provincial Injury Prevention
Safe Healthy Environments
Provincial Population and Public Health
injury.prevention@ahs.ca
Carol Beringer
Health Promotion Facilitator
Provincial Injury Prevention
carol.beringer@ahs.ca
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Table of Contents
Table of Figures ......................................................................................................................... 3
Introduction ................................................................................................................................ 4
Injuries to Children as Passengers in Motor Vehicle Collisions in Alberta................................... 4
The Costs of Transport Incidents ............................................................................................... 6
A Review of Best Practice Recommendations ........................................................................... 6
The Safe System Approach .................................................................................................. 6
The Use of Car Seats, Booster Seats and Seat Belts for Children........................................ 7
Improving the Safety of Passengers Who Are Five to Nine Years of Age ............................. 7
Evidence-based Recommendations for Car Seat, Booster Seat and Seat Belt Use for Children 9
Seating location of children in the vehicle ....................................................................... 9
Car seats, rear-facing ..................................................................................................... 9
Car seats, forward-facing................................................................................................ 9
Booster seats ................................................................................................................. 9
Seat belts ....................................................................................................................... 9
Reduce health inequities in child passenger safety ........................................................ 9
Possible Next Steps to Improve Child Passenger Safety in Alberta ...........................................10
Conclusion ................................................................................................................................11
References ...............................................................................................................................12
Appendix A - 2017 Recommendations for Car Seat, Booster Seat and Seat Belt Use for
Children ...............................................................................................................................14
Appendix B - Review of Best Practice Child Restraint Use Recommendations, 2022 .........15
Appendix C – Booster Seat Legislation in Canada, February 2022 .....................................19
Table of Figures
Figure 1: Alberta ED/UCC Visits due to Motor Vehicle Collisions, Crude Rate (per 100K),
Children < 15 years (Passenger/Driver only), 2015-2020* ........................................... 5
Figure 2: Alberta Hospitalizations due to Motor Vehicle Collisions, Crude Rate (per 100K),
Children < 15 years (Passenger/Driver only), 2015-2020* ........................................... 5
Figure 3: Total Costs in Millions by Type of Cost, Transport Incidents, Children (0-14 years),
both sexes, Canada, 2018 .......................................................................................... 6
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Introduction
The Recommendations for Car Seat, Booster Seat and Seat Belt Use for Children came out in
2017 (see Appendix A). The related Car Seat and Booster Seat YES Test resources
(2017) give
parents and caregivers useful information on when and how to choose and use rear-facing car
seats, forward-facing car seats, booster seats and seat belts for child passengers. AHS
Provincial Injury Prevention (PIP) reviews program resources regularly. A 2021-22 review of the
statements of key injury prevention, pediatric medicine and traffic safety organizations regarding
the use of car seats, booster seats and seat belts for children found an important change in the
recommendations for the use of rear-facing car seats since 2017.
This report will highlight the most recent data on injuries to child passengers in motor vehicle
collisions, review the best practices for child passenger safety, and propose updated safety
recommendations for motor vehicle passengers under 15 years of age.
Injuries to Children as Passengers in Motor
Vehicle Collisions in Alberta
Injuries to children and youth (≤ 19 years) as passengers in motor vehicle crashes decreased
significantly across Canada between 2006 and 2012 (Fridman et al., 2018). The AHS Injury
Surveillance Dashboard tracks the numbers and rates of Emergency Department & Urgent Care
Centre (ED/UCC) visits and hospitalizations in Alberta. Figure 1 shows the change in the crude
rates of ED/UCC visits for injuries to child occupants in motor vehicle collisions in Alberta
between 2015 and 2020. Figure 2 illustrates the rates of hospitalization of child passengers for
the same period. Hospitalization rates are typically much lower than ED/UCC visit rates and
often reflect injury that is more serious.
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Figure 1: Alberta ED/UCC Visits due to Motor Vehicle Collisions, Crude Rate (per
100,000), Children under 15 years (Passenger/Driver only), 2015-2020*
*COVID-19 pandemic
**Ages: “Birth-4 years old” = up to and including the day before the 5
th
birthday; “5-9 years old” = up to and including
the day before the 10
th
birthday; “10-14 years old” = up to and including the day before the 15
th
birthday.
Figure 2: Alberta Hospitalizations due to Motor Vehicle Collisions, Crude Rate (per
100,000), Children under 15 years (Passenger/Driver only), 2015-2020*
*COVID-19 pandemic
**Ages: “Birth-4 years old” = up to and including the day before the 5
th
birthday; “5-9 years old” = up to and including
the day before the 10
th
birthday; “10-14 years old” = up to and including the day before the 15
th
birthday.
68.0
64.6
59.2
54.2
54.4
37.2
117.6
118.1
123.7
124.7
123.7
76.2
181.8
185.0
185.8
176.4
163.7
132.0
0
40
80
120
160
200
2015 2016 2017 2018 2019 2020*
Alberta ED/UCC Visits due to Motor Vehicle Collisions,
Crude Rate (per 100,000), Children under 15 years
(Passenger/Driver only), 2014-2020*
Birth-4 years old**
5-9 years old**
10-14 years old**
6.3
5.1
3.3
4.0
3.3
3.0
4.2
4.1
3.7
5.1
4.7
5.0
11.6
10.5
13.0
10.2
7.9
9.9
0
2
4
6
8
10
12
14
2015 2016 2017 2018 2019 2020*
Alberta Hospitalizations due to Motor Vehicle Collisions,
Crude Rate (per 100,000), Children under 15 years
(Passenger/Driver only), 2015-2020*
Birth-4 years old**
5-9 years old**
10-14 years old**
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
As 2020 was the first year of the COVID-19 pandemic, the decreased rates of ED/UCC visits for
injuries to child passengers in Alberta in 2020 could be because of fewer vehicles on the roads
due to pandemic restrictions. Figures 1 and 2 illustrate an overall decrease over time of the
rates of injury to child passengers from birth to four years of age (up until the day before the 5
th
birthday) in Alberta. Of concern, the rate of hospitalizations for child passengers five to nine
years of age increased between 2015 and 2020. This could mean that children that age are
more seriously hurt in crash situations and thus require admission to hospital for treatment. Five
to nine year olds are children who are often too big for a forward-facing car seat with a harness,
but too small for an adult seat belt. These children are safest riding in a booster seat because
the booster seat boosts them up so the adult seat belt fits them correctly.
The Costs of Transport Incidents
Falls and transport incidents had the highest total costs of injury for Canadians in 2018
(Parachute Canada, 2021). For children under 15 years in Canada, of all the types of transport
incidents, motor vehicle-related injuries had the highest total costs, exceeding $83 million CAD
in 2018.
Figure 3: Total Costs in Millions by Type of Cost, Transport Incidents, Children (0-14
years), both sexes, Canada, 2018
*Other transport includes railway, air and water transport, industrial vehicles and unknown.
A Review of Best Practice Recommendations
The Safe System Approach
In 2021, the World Health Organization (WHO) and United Nations General Assembly released
the Global Plan for a Decade of Action for Road Safety, 2021-2030. The target is to reduce road
traffic deaths and injuries by at least 50% by 2030. The Global Plan calls on governments and
stakeholders who influence road safety to take a new path that recognizes road transport as a
complex system and prioritizes the safety of all road users. This Safe System approach puts
$0
$20
$40
$60
$80
$100
Motor vehicle Pedal cycle Pedestrian ATV,
snowmobile
Other
transport*
Costs in Millions
Direct costs Indirect costs
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
peoples’ safety at the center in the interactions of three components: humans, vehicles, and the
road infrastructure. It prioritizes safe mobility as a human right (WHO, 2021).
Vision Zero is a safe systems initiative underway in various Alberta locations. “Vision Zero is a
strategy to eliminate all traffic fatalities and severe injuries, while increasing safe, healthy,
equitable mobility for all” (Vision Zero Network, n.d.). Alberta locations that have adopted Vision
Zero include the cities of Edmonton (2015), St. Albert (2018), Calgary (2018) and Ft.
Saskatchewan (2019). Both Vision Zero and the Global Plan address the safety of all users of
the road transport system; they emphasize that no one should be killed or seriously injured on
the road. Occupant protection (safety belts and child-restraint systems) is included in the safe
systems approach as part of both vehicle safety and safe road use. The Global Plan identifies
the enactment and enforcement of legislation mandating the use of protective equipment,
including child car seats and booster seats, as a recommended action to ensure safe road use
(WHO, 2021).
The Use of Car Seats, Booster Seats and Seat Belts for Children
In 2022, PIP conducted an environmental scan of five prominent injury prevention, pediatric
medicine and traffic safety organizations to compile best practice recommendations for the use
of car seats, booster seats and seat belts for children. PIP reviewed the websites of the
Canadian Paediatric Society (CPS), Transport Canada (TC), Parachute Canada, Child Safety
Link (CSL) and the American Academy of Pediatrics (AAP). PIP compared the
recommendations of each organization with the 2017 AHS Recommendations for Car Seats,
Booster Seats and Seat Belts for Children (see Appendix B
).
Although the wording varies, there is consistency on most aspects of the recommendations of
the CPS (2020), TC (2019), Parachute Canada (2021), CSL (2021) and the AAP (2018, 2021).
Of note, the AAP published a technical report late in 2018 that included a change to their best
practice recommendation for the use of rear-facing car safety seats. Citing the retraction of a
published study and further analysis of injury data, the 2018 AAP technical report removed “at
least 2 years of age” as a criterion for moving a child from a rear-facing to a forward-facing seat.
AAP’s best practice recommendation stated, “All infants and toddlers should ride in a rear-facing
car safety seat as long as possible, until they reach the highest weight or height allowed by the
seat’s manufacturer” (AAP, 2018). AAP revised their guideline in 2021 to say, “All infants and
toddlers should ride in a rear-facing seat until they reach the highest weight or height allowed by
their car safety seat manufacturer.” The removal of ‘”at least 2 years of age” criterion by AAP
played a role the revisions to AHS wording for recommended car seat use.
Improving the Safety of Passengers Who Are Five to Nine Years of Age
The increase in the rate of hospitalizations of child passengers in Alberta who are five to nine
years old (Figure 2
) is a concern. Alberta is the only province in Canada that does not have
booster seat legislation to protect children who weigh more than 18 kg (40 lbs.) after they
have outgrown a forward-facing car seat
(see Appendix C). This constitutes a wide gap
between safety practices in Alberta and best practices in child passenger safety.
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Evidence-based Recommendations for Car
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March 2023
A 2019 survey on child passenger restraint use completed by 4,026 Alberta parents/caregivers
who had driven 7,134 children under the age of 13 in the previous six months highlighted gaps
in knowledge and practice of booster seat use. Respondents expressed uncertainty about
booster seat use in Alberta. They requested increased education on when to use a booster seat
and when to transition to a seat belt. Survey respondents also requested that adherence to child
occupant restraint legislation be supported by enforcement (AHS, 2019).
A literature review conducted by PIP in 2014 found numerous studies that showed significant
improvement in booster seat use and decreased injury rates in jurisdictions with booster seat
legislation (AHS, 2014). A subsequent rapid review in 2022 found additional evidence for the
effectiveness of booster seat legislation with a focus on older child passengers:
• Booster seat legislation in British Columbia was associated with a 10.8% reduction in the
rate of injuries to children between 4 and 8 years old within four years (Brubacher et al.,
2016).
• Laws in the United States with higher age requirements for mandatory child safety seat use
were effective in increasing the age of children in safety seats (Jones & Ziebarth, 2017).
• The use of a booster seat for older children (between 8 and 12 years old) was associated
with a 19% reduction in the odds of experiencing any injury in a motor vehicle crash relative
to using a seat belt alone (Anderson et al., 2017).
• An Alberta study using police collision report data from Edmonton and Calgary found that
child passengers between four and 8 years old restrained with a seat belt had higher odds
of injury compared to those in a booster seat, particularly in certain types of crashes (Pitt et
al., 2021). The authors concluded that the introduction of booster seat legislation in Alberta
could lower the injury rates for children between four and 8 years old, increase booster seat
use, and reduce the number of children sitting in the front seat.
• A 2016 Alberta study on booster seat use also concluded that enacting booster seat
legislation in the province would be an important step for safety, emphasizing that messages
need to educate drivers about when to transition kids from booster seats to seat belts, and
to keep passengers under 9 years out of the front seat (Golonka et al., 2016).
• A systematic review to describe associations between child passenger safety legislation and
safety outcomes found that legislation appears to be positively associated with both the use
of child restraints and with fewer injuries and deaths to child passengers (Sartin et al.,
2021). The authors cautioned that legislation may have nuanced, potentially negative effects
among at-risk populations such as those with less formal education, lower incomes, and
ethnic/racial minorities. They suggest tailored and effective messaging when introducing
legislation to reach at-risk populations, including information in multiple languages and using
a variety of platforms (e.g. online, paper, in person).
• The introduction of child passenger safety legislation in Israel in 2004 reduced yearly traffic
injury and death rates for children aged 0-4 years and 5-9 years (Nazif-Muniz et al., 2018).
The authors point to timely and repetitive awareness campaigns that stress the need to
properly install and use each of the safety seat types (car seat, booster seat) as key to
maintaining the effectiveness of legislation over time.
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
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March 2023
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
Based on this review of injury data, costs and best practices, these are the recommendations to
improve the safety of children travelling as passengers in motor vehicles in Alberta:
Seating location of children in the vehicle
• Children under the age of 13 are safest in the back seat.
Car seats, rear-facing
• A rear-facing seat provides the best protection for a child’s head, neck and spine in a
sudden stop or crash.
• Infants and young children are safest riding in a rear-facing car seat until they reach the
maximum height or weight limit for rear-facing use allowed by the seat's manufacturer.
• When your baby outgrows their infant seat, move them into a larger rear-facing seat.
• Your child is safest riding rear facing until 2, 3 or even 4 years old.
Car seats, forward-facing
• When a child outgrows their larger rear-facing car seat (by height or weight), they should
move into a forward-facing car seat with a harness.
• Use a forward-facing car seat with a harness until your child reaches that seat’s
maximum height or weight limit.
Booster seats
• When a child outgrows their forward-facing car seat with a harness (by height or weight),
they should move to a booster seat.
• A child is safest in a booster seat until they reach the maximum height or weight limit of
the booster seat.
• Use a booster seat until the vehicle lap and shoulder seat belt fits properly (see
recommendation 5); this is typically when your child is 145 cm (4 ft. 9 in.) tall and
between 8 and 12 years of age.
Seat belts
Children can usually use a seat belt when they are at least 145 cm (4 ft. 9 in.) tall, because:
• Their knees will bend comfortably at the edge of the seat when sitting all the way back,
• The lap belt will stay low and snug across their hip bones,
• The shoulder belt will cross the chest and stay between their neck and shoulder, and
• They can likely sit like this for the whole trip without slouching.
Reduce health inequities in child passenger safety
• Develop tailored and effective messaging in consultation with communities to reach at-
risk populations, including information in multiple languages and using a variety of
formats.
10
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
• Consider timely and repetitive awareness campaigns that stress the need to properly
install and use each of the safety seat types (car seat, booster seat).
• Enhance the economic and social circumstances across Alberta to:
o Facilitate access to correct car seat information in a language and format that
parents/caregivers understand.
o Improve the availability of safe, affordable car seats and booster seats in
communities across the province.
Possible Next Steps to Improve Child
Passenger Safety in Alberta
1. Advocate for provincial booster seat legislation to protect the safety of children up to
145 cm (4’9”) tall or 9 years of age.
• Key leaders/stakeholders and members of the public should advocate for the
introduction of booster seat legislation in Alberta.
• Legislation would likely include revisions to the Alberta Traffic Safety Act, Vehicle
Equipment Regulation (Part 5 Occupant Restraint Systems) to add a requirement for
booster seat use that aligns with best practices in child passenger safety.
2. Revise and update existing car seat, booster seat and other child seat resources, in
collaboration with Zones and key stakeholders.
• Develop tailored and effective messaging, in consultation with communities, to reach
parents/caregivers, including at-risk populations.
• Provide messages in a suitable variety of languages and formats.
3. Share these recommendations and resources with health, childcare, injury
prevention and traffic safety partners across the province.
• Encourage stakeholders to consider timely and repetitive initiatives to promote the
proper installation and use each of the car seat types (rear-facing and forward-facing
car seats, booster seats).
4. Continue to raise awareness and educate parents/caregivers across the province of
the correct use of car seats, booster seats and seat belts for children.
• Continue to include information on car seats and booster seats in pre-natal, post-
partum and well child public health materials.
• Support AHS staff who have contact with young families to learn the key messages for
child passenger safety.
• Consider timely and repetitive awareness campaigns that stress the need to properly
install and use each of the safety seat types (car seat, booster seat).
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
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March 2023
Conclusion
Injuries to children as passengers in motor vehicles continue to decrease in Alberta and
elsewhere. Correct restraint of children under 15 in car seats, booster seats and/or seat belts
helps keep them safe should a crash occur. The choice of the correct safety seat depends on
the child’s size (height and weight) and the maximum height and weight limits of their car seat or
booster seat. These Recommendations provide parents and caregivers, health professionals
and all Albertans with guidance for how to keep their young passengers safe when riding in a
motor vehicle. Particular attention is needed to ensure that children who outgrow a forward-
facing car seat with a harness move to a booster seat until they are at least 145 cm (4’ 9”) tall
and between 8 and 12 years of age.
Back
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
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March 2023
References
Alberta Health Services, Provincial Injury Prevention Program. (2014). Booster seat intervention
strategies: Findings from a literature review. (mailto:[email protected]
to request
PDF).
Alberta Health Services, Provincial Injury Prevention Program. (2017). Recommendations for
Car Seat, Booster Seat and Seat Belt Use for Children. (mailto:[email protected]
to
request PDF).
Alberta Health Services, Provincial Injury Prevention Program & Research and Innovation.
(2019). Alberta Car Seat, Booster Seat and Seat Belt Evaluation and Education Study Final
Report. (mailto:injury.prev[email protected] to request PDF).
American Academy of Pediatrics. (2018). Policy statement – Child passenger safety. Pediatrics,
142(5), e20182460. https://doi.org/10.1542/peds.2018-2460
American Academy of Pediatrics. (2021, December 22). Car seats: Information for families.
https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-
Seats-Information-for-Families.aspx
Brubacher, J. R., Desapriya, E., Erdelyi, S. & Chan, H. (2016). The impact of child safety
restraint legislation on child injuries in police-reported motor vehicle collisions in British
Columbia: An interrupted time series analysis. Paediatrics & Child Health, 21(4), e27-e31.
https://doi.org/10.1093/pch/21.4.e27
Canadian Paediatric Society. (2020, December). Car seat safety.
https://caringforkids.cps.ca/handouts/safety-and-injury-prevention/car_seat_safety
Child Safety Link. (2021). Car seat safety. IWK Health Centre. https://childsafetylink.ca/car-seat-
safety
Durbin, D. R., Hoffman, B. D., Agran, P. F., Denny, S. A., Hirsh, M., Johnston, B., Lee, L. K.,
Monroe, K., Schaechter, J., Tenenbein, M., Zonfrillo, M. R., & Quinlan, K. (2018, November
1). Child passenger safety. American Academy of Pediatrics.
https://doi.org/10.1542/peds.2018-2460
Fridman, L., Fraser-Thomas, J. L., Pike, I. & Macpherson, A. K. (2018). Childhood road traffic
injuries in Canada – a provincial comparison of transport injury rates over time. BMC Public
Health, 18: 1348. https://doi.org/10.1186/s12889-018-6269-9
Golonka, R. P., Dobbs, B. M. Rowe, B. H. & Voaklander, D. (2016). Prevalence and predictors
of booster seat use in Alberta, Canada. Can J Public Health 107(2): e155–e160.
https://doi.org/10.17269/cjph.107.5254
Jones, L. E. & Ziebarth, N. R. (2017). U.S. child safety seat laws: Are they effective, and who
complies? Journal of Policy Analysis and Management, 36(3), 584–607.
Nazif-Munoz JI, Blank-Gommel A, Shor E. (2018). Effectiveness of child restraints and booster
legislation in Israel. Injury Prevention, 24: 405–411.
http://dx.doi.org/10.1136/injuryprev-
2017-042458
Parachute Canada. (2021, November). Choosing the right car seat.
https://parachute.ca/en/injury-topic/car-seats/choosing-the-right-car-seat/
13
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Pitt, T. M., Howard, A. W., HubkaRao, T. & Hagel, B. E. (2021). The effectiveness of booster
seat use in motor vehicle collisions. Accident Analysis and Prevention, 159.
https://doi.org/10.1016/j.aap.2021.106296
Sartin, E. B., Lombardi, L. R. & Mirman, J. H. (2021). Systematic review of child passenger
safety laws and their associations with child restraint system use, injuries and deaths. Injury
Prevention, 27, 577-581. http://dx.doi.org/10.1136/injuryprev-2021-044196
Transport Canada. (2019, October). Choosing a child car seat or booster seat.
https://tc.canada.ca/en/road-transportation/child-car-seat-safety/choosing-child-car-seat-
booster-seat
Vision Zero Network. (n.d.) What is Vision Zero? https://visionzeronetwork.org/about/what-is-
vision-zero
World Health Organization (WHO). (2021). Global Plan for the Decade of Action for Road Safety
2021-2030.
https://www.who.int/publications/m/item/global-plan-for-the-decade-of-action-for-
road-safety-2021-2030
Back
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Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Appendix A - 2017 Recommendations for Car Seat, Booster Seat
and Seat Belt Use for Children
1. Seating location of children in the vehicle
• Children under the age of 13 are safest in the back seat.
2. Car seats, rear-facing
• A child is safest staying rear-facing until he/she is at least 2 years of age or reaches
the maximum height or weight limit of the rear-facing seat, as stated by the
manufacturer.
• A rear-facing seat provides the best protection for a child’s head, neck and spine in a
sudden stop or crash.
• Many rear-facing car seats are designed with higher weight and height limits beyond
2 years of age, these models are preferred.
3. Car seats, forward-facing
• Once a child is at least 2 years of age or reaches the maximum height or weight limit
of their rear-facing car seat, as stated by the manufacturer, he/she can move into a
forward-facing car seat.
• Use a forward-facing car seat until the child reaches the maximum height or weight
limit of that seat, as stated by the manufacturer.
4. Booster seats
• Once a child reaches the maximum height or weight limit of their forward-facing car
seat, as stated by the manufacturer, he/she can move into a booster seat.
• A child is safest in a booster seat until he/she reaches the maximum height or weight
limit of that seat, as stated by the manufacturer.
• A child is ready to exit his/her booster seat when the vehicle seat belt fits properly
(see recommendation 5); this is typically when a child is 145 cm (4’9”) tall and
between 8 and 12 years of age.
5. Seat belts
Children can safely use a seat belt when
• They are at least 145 cm (4 feet 9 inches) tall.
• Their knees bend comfortably at the edge of the seat when sitting all the way back.
• The lap belt stays low and snug across the hip bones.
• The shoulder belt crosses the chest and stays between your child’s neck and shoulder.
• They can sit like this for the whole trip without slouching.
• Until your child can meet all 5 steps, continue using a booster seat on every ride.
Back
15
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Appendix B -
Review of Best Practice Child Restraint Use Recommendations, 2022
Rear-facing Car Seats
Organization (website)
Recommendation
Comparison to 2017 AHS
Canadian Paediatric Society
(https://caringforkids.cps.ca/han
douts/safety-and-injury-
prevention/car_seat_safety)
All infants must use a rear-facing car seat. A rear-
facing seat provides the best protection for your child’s
head, neck, and spine in a sudden stop or crash. Once
your baby outgrows the infant seat, use a larger, rear-
facing seat. As long as your child still fits within the
manufacturer’s weight and height limits, they are
safest using a rear-facing seat until 2, 3, or even 4
years old.
Uses the term 'infant seat' and
'larger, rear-facing seat' for
rear-facing seats that are
combined with another stage.
Recommends rear-facing “until
2, 3 or even 4 years old.” AHS
stated at least 2 years of age.
Transport Canada (TC)
(https://tc.canada.ca/en/road-
transportation/child-car-seat-
safety/choosing-child-car-seat-
booster-
seat#_The_four_stages)
Infants and young children ride facing the rear in an
infant seat with a detachable base or in a convertible
seat. This helps protect their head, neck and back
throughout the journey, during sudden stops or in a
crash. All child car seats have a recommended recline
angle based on the weight of your child. For example,
newborns and premature babies need to be tilted back
more than older
babies. This helps support the head and
helps to keep their airway open. Keep your child seated
rear- facing until they reach the child car seat's
weight or
height limits.
TC does not indicate an age
while AHS stated at least 2
years of age.
Parachute
(https://parachute.ca/en/injury-
topic/car-seats/choosing-the-
right-car-seat/)
Infant and rear-facing seat
Use
from birth to seat height or weight limit.
•
Canadian law requires that newborns and infants
use a rear-facing car seat.
•
Infants must use rear-facing car seats until they are
at least one year of age and weigh at least 10 kg
(22 lbs.).
•
Keep your child rear-facing for as long as they still
fit the larger, rear-facing seat. Your child is safest
riding rear facing until two, three or even four years
old, as long as they still fit within the height and
weight limits for the seat.
•
The rear-facing position is safest and many
manufacturers are now making car seats that fit
heavier and taller children.
Parachute states, “Your child is
safest riding rear facing until
two, three or even four years
old, as long as they still fit within
the height and weight limits for
the seat.” AHS stated at least 2
years of age.
Child Safety Link (CSL) Nova
Scotia
(https://childsafetylink.ca/car-
seat-safety and
https://childsafetylink.ca/sites/de
fault/files/2022-
06/2021%20CSL%20English%2
0postcard.pdf)
Rear-facing car seats
A rear
-facing seat gives the best protection for your
child’s head, neck, and
spine in a sudden stop or
crash. Your child is safest riding rear
-facing until 2, 3,
or even 4 years old. Keep your child rear facing as
long as they still fit within the height and weight limits
for their larger, rear
-facing seat. Read your vehicle
manual
and follow the instructions for your seat.
CSL has a separate entry for
infant (rear-facing only) seats.
Uses the term 'infant seat' for
rear-facing only and 'larger,
rear-facing seat' for rear-facing
seats that are combined with
another stage.
Recommends rear-facing
“until 2, 3 or even 4 years
old.” AHS stated at least
2 years of age.
American Academy of
Pediatrics (AAP)
(https://www.healthychildren.org
/English/safety-prevention/on-
the-go/Pages/Car-Safety-Seats-
Information-for-Families.aspx
All infants and toddlers should ride in a rear-facing seat
until they reach the highest weight or height allowed by
their car safety seat manufacturer. Most convertible
seats have limits that will allow children to ride rear
facing for 2 years or more (2022).
AHS' 2017 rear-facing wording
was consistent AAP at that time
(rear-
facing until at least 2 years
of age or…). AAP published
new wording in 2018, and
further revised wording on their
‘for families’ site in 2021.
16
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Forward-facing Car Seats
Organization (website)
Recommendation
Comparison to 2017 AHS
Canadian Paediatric Society
(https://caringforkids.cps.ca/ha
ndouts/safety-and-injury-
prevention/car_seat_safety)
Once your child has outgrown the larger rear- facing car
seat – and is at least 2 years old – they can move to a
forward-facing car seat with a 5- point harness.
Keep your child in a 5-point harness until they weigh at
least 18 kg (40 lb.) and can sit straight and tall without
moving out of position or unbuckling. This may be at 4,
5, or even 6 years old. If your child outgrows the seat
before they can sit correctly, you may need a 5- point
harness that will hold a taller, heavier child.
Criteria for graduation from
forward-facing seat differs. TC
says 18 kg (40 lb.
) plus age and
other criteria, AHS said until
maximum weight or height of
forward-facing seat.
Transport Canada (TC)
(https://tc.canada.ca/en/road-
transportation/child-car-seat-
safety/choosing-child-car-seat-
booster-
seat#_The_four_stages)
Children who have outgrown their rear-facing seat
and weigh at least 10 kg (22 lb) may ride facing the
front in a child car seat. These child car seats have a
built-in harness designed to keep your child safe
throughout the journey, during sudden stops or a crash.
Use a forward-facing seat until your child reaches the
maximum weight or height limits for the child car seat.
Some forward-facing seats are made for children who
weigh up to 30 kg (65 lb.).
TC does not indicate an age to
start using a forward-facing
seat, while AHS stated
at least 2
years of age.
Parachute
(https://parachute.ca/en/injury-
topic/car-seats/choosing-the-
right-car-seat/)
Forward-facing seat
Use after child grows out of rear-facing seat to at least
18 kg (40 lbs.) and is at least 2 years old.
•
Use a forward-facing car seat with a five-point
harness until their height or weight exceeds the
restrictions for the model they are using: this may be
at 4, 5, or even 6 years old.
•
Then either purchase another forward-facing seat
designed for larger children or move to a booster
seat.
•
Forward-facing car seats use a tether strap to
prevent the top of the car seat from moving
forward too much during a collision.
•
Choose a forward-facing car seat that fits a higher
range of height and weight so that a child can use it
for longer.
Parachute indicates a forward-
facing seat after a child grows
out of the rear-facing seat to at
least 18 kg (40 lbs.) and is at
least 2 years old. AHS said until
maximum weight or height of
forward-facing seat.
Email sent to Parachute May
26, 2022 to clarify age
reference. Reply received on
June 27, 2022 states, “We will
remove the age mention and
align with Transport Canada’s
current recommendations.”
Child Safety Link (CSL) Nova
Scotia
(https://childsafetylink.ca/car-
seat-safety and
https://childsafetylink.ca/sites/de
fault/files/2022-
06/2021%20CSL%20English%2
0postcard.pdf)
Forward-facing car seats
A forward
-facing seat uses a five-point harness to
spread the for
ce of a sudden stop or crash over the
strongest parts of your child’s body. Keep your child in a
five
-point harness until they weigh at least 18kg (40
pounds). Always remember to read your vehicle manual
and follow the instructions for your seat.
CSL doesn't indicate an age
to start using a forward-
facing seat, while AHS
stated at least 2 years of
age
American Academy of
Pediatrics (AAP)
(
https://www.healthychildren.org
/English/safety-prevention/on-
the-go/Pages/Car-Safety-Seats-
Information-for-Families.aspx)
Children who have outgrown the rear-facing weight or
height limit for their convertible safety seat should use a
forward-facing seat with a harness for as long as
possible, up to the highest weight or height allowed by
their car safety seat manufacturer. Many seats can
accommodate children up to 65 pounds or more.
AAP uses 'should,' AHS used
'can'; AAP gives consistent
criteria for transitions (outgrow
highest weight or height limit
allowed by car safety seat
manufacturer). AAP uses
phrase 'as long as possible' for
forward-facing, although not for
rear-facing (a change from Nov
2021).
17
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Booster Seats
Organization (website)
Recommendation
Comparison to 2017 AHS
Canadian Paediatric Society
(https://caringforkids.cps.ca/ha
ndouts/safety-and-injury-
prevention/car_seat_safety)
When your child is at least 18 kg (40 lb.) and at
least 4 years old, and has outgrown their forward-
facing car seat with a 5-point harness, they may be
ready to move to a belt-positioning booster seat. To
safely use a booster seat, your child must be able to
sit correctly. Keep your child in a booster seat until
they safely fit the adult seat belt. For most children,
this will be between 9 and 12 years old.
Criteria for graduation from
forward-facing seat differs.
CPS says 18 kg (40 lb.) plus
age and other criteria, AHS
said until maximum weight or
height of forward-facing seat.
CPS uses term 'belt-
positioning booster seat.' CPS
does not refer to weight or
height limit of booster seat as
graduation criteria.
Transport Canada (TC)
(https://tc.canada.ca/en/road-
transportation/child-car-seat-
safety/choosing-child-car-seat
-
booster-
seat#_The_four_stages)
Booster seats are designed for children who have
outgrown their forward-facing seat and weigh at
least 18 kg (40 lb). A booster seat helps children sit
comfortably by raising them up so they can sit up
against the seatback with their knees bent over the
edge of the booster o
r vehicle seat. Even if a booster
seat meets Canadian regulations, the booster seat
you choose needs to fit your child, and your vehicle.
TC outlines weight of at least
18kg (40 lbs.) to move to
booster. AHS stated to use
forward-facing car seat to the
manufacturer’s maximum
weight or height limit.
Parachute
(https://parachute.ca/en/injury-
topic/car-seats/choosing-the-
right-car-seat/)
Booster seat
Use from when a child is a minimum of 18 kg (40
lbs.) to 145 cm tall (4 ft., 9 in) and is at least 4 years
old.
Parachute suggests a min. of
18 kg (40 lbs.) to get into a
booster and 145 cm tall (4ft,
9in) to graduate to a seat belt.
AHS suggested using the
manufacturer's weight or
height limits to decide.
Child Safety Link (CSL)
Nova Scotia
(https://childsafetylink.ca/car-
seat-safety)
Booster Seat
•
A booster seat lifts the child up so that the adult
seat belt fits across the strongest bones.
•
Your child must weigh at least 18 kg (40 pounds)
to use a booster seat.
•
Your child must be able to sit straight and tall
without moving around or unbuckling.
•
Use a booster seat until your child is at least 145
cm (4 feet 9 inches) tall and fits the seat belt
correctly.
Criteria for graduation from
forward-facing seat differs
from AHS, CSL has no
reference to weight or height
of forward-facing seat. CSL
says 18 kg (40 lb.) plus age
and other criteria, CSL does
not refer to weight or height
limit of booster seat as
graduation criteria.
American Academy of
Pediatrics (AAP)
(https://www.healthychi
ldren.or
g/English/safety-
prevention/on-the-
go/Pages/Car-Safety-Seats-
Information-for-Families.aspx)
All children whose weight or height exceeds the
forward
-facing limit for their car safety seat should
use a belt
-positioning booster seat until the vehicle
seat belt fits properly, typically when they have
reached 4 feet 9 inches in height and are 8 to 12
years of age.
All children younger than 13 years
should ride in the back seat.
AAP says 'should use a belt-
positioning booster seat'; AHS
says 'can move into a booster
seat.' Content is similar but
AHS used more words.
18
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Seat Belts
Organization
(website)
Recommendation
Comparison to 2017 AHS
Canadian Paediatric Society
(https://caringforkids.cps.ca/han
douts/safety-and-injury-
prevention/car_seat_safety)
Once your child is
at least 145 cm (4’ 9”) tal
l, they
may be ready to start using an adult
seat belt
. In
order to fit safely:
•
Your child’s knees must bend comfortably at the
edge of the vehicle seat when sitting all the way
back.
•
The lap belt must stay low and snug across your
child’s hips.
•
The shoulder belt must cross the chest and stay
between the neck and shoulder.
If your child cannot sit like this for the w
hole trip
without slouching, continue to use a booster seat.
Consistent.
Transport Canada (TC)
(https://tc.canada.ca/en/road-
transportation/child-car-seat-
safety/choosing-child-car-seat-
booster-
seat#_The_four_stages)
The vehicle seat belt should only be used alone when
children have outgrown their booster seats.
Before you
transition to this important stage make sure the seat
belt fits your child. The minimum age, weight and
height limits vary from one province to another.
Consistent
.
Parachute
(https://parachute.ca/en/injury-
topic/car-seats/choosing-the-
right-car-seat/)
Seatbelt alone
Use when a child is taller than 145 cm (4 ft. 9 in).
Seatbelts are designed for adult bodies. For this
reason, it is important that parents check where the
lap and shoulder belts rest on their older child’s
body.
Do this five-step test to see if your child is ready to
move from a booster seat to a seat belt:
•
The child can sit all the way back against the
back of the vehicle seat.
•
The knees bend comfortably over the edge of
the vehicle seat without slouching.
•
The lap belt fits low and snug across the hips
and doesn’t ride up on the stomach.
•
The shoulder belt goes across the chest bone
and the middle of the shoulder, not touching the
neck and never behind the back.
•
The child can sit properly for the entire trip.
Consistent
.
Child Safety Link (CSL) Nova
Scotia
(https://childsafetylink.ca/car-
seat-safety)
Can your child safely use a seat belt?
•
Is your child at least 145 cm (4 feet 9 inches)
tall?
•
Do your child’s knees bend comfortably at the
edge of
the seat when they are sitting all the way
back?
•
Does the lap belt stay low and snug across the
hip bones?
•
Does the shoulder belt cross the chest and stay
between your child’s neck and shoulder?
•
Can your child sit like this for the whole trip
without slouching?
Until
your child can meet all 5 steps, keep using a
booster seat on every ride.
Consistent.
American Academy of
Pediatrics (AAP)
(https://www.healthychildren.org
/English/safety-prevention/on-
the-go/Pages/Car-Safety-Seats-
Information-for-Families.aspx)
When children are old enough and large enough for
the vehicle seat belt to fit them correctly, they should
always use lap and shoulder seat belts for the best
protection.
All children younger than 13 years should
ride in the back seat.
Consistent.
Back
19
Evidence-based Recommendations for Car
Seat, Booster Seat and Seat Belt Use for
Children
March 2023
Appendix C – Booster Seat Legislation in Canada, February 2022
Province
Booster Seat Legislation
British Columbia
Children must ride in a booster seat until they are a minimum of 4
feet, 9 inches (145 cm) tall, or a minimum of 9 years old.
Alberta
No provincial law.
Saskatchewan
Children must ride in a booster seat until they are a minimum of 4
feet, 9 inches (145 cm) tall and 80 pounds (36 kg), or a minimum of 7
years old.
Manitoba
Children must ride in a booster seat until they are a minimum of 4
feet, 9 inches (145 cm) tall and a minimum of 80 pounds (36 kg), or a
minimum of 9 years old.
Ontario
Children must ride in a booster seat until they are a minimum of 4
feet, 9 inches (145 cm) tall, or a minimum of 80 pounds (36 kg), or a
minimum of 8 years old.
Quebec
Children must ride in the appropriate car seat or booster seat until
they are a minimum of 4 feet, 9 inches (145 cm) tall or a minimum of
9 years old. The car seat or booster seat must, in accordance with the
manufacturer’s instructions, be suitable for the child’s height and
weight and be securely attached to the vehicle.
New Brunswick
Children must ride in a properly secured, appropriate car seat or
booster seat until they are a minimum of 4 feet, 9 inches (145 cm) tall,
or a minimum of 80 pounds (36 kg), or a minimum of 9 years old.
Nova Scotia
Children must ride in a booster seat when they are a minimum of 40
pounds (18 kg) until they are a minimum of 4 feet, 9 inches (145 cm)
tall, or a minimum of 9 years old.
Prince Edward Island
Children must ride in a booster seat if they are over 40 pounds (18
kg). The child must continue to use a booster seat until they are 4
feet, 9 inches (145 cm) tall, or a minimum of 10 years old.
Newfoundland and
Labrador
Children must ride in a booster seat until they are a minimum of 4
feet, 9 inches (145 cm) tall, or a minimum of 80 pounds (36 kg), or a
minimum of 8 years old.
Yukon
Child must weigh over 22 kg (48 lb.). A booster seat is required until
at least 145 cm (4’9”) or 45 kg (100 lb.), whichever comes first.
Northwest Territories
No provincial/territorial law.
Nunavut
No provincial/territorial law.
Back
