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July 24, 2018

Child Restraints and Car Seat Safety

Welcome again to the pediatric blog! I hope that everyone’s summer is going well. Since we are in full swing of summer, which tends to be a busy travel time for families – vacations, day trips, etc., I thought that this month’s blog should focus on something related to this; therefore, this month’s pediatric blog is going to focus on car seat safety and what the laws in North Carolina are around child restraints. 

First and foremost, it is important to check the manufacturer’s (Graco, Britax, etc.) specifications for the particular seat you are using. All car seats made in the United States are required by federal law to have specification regarding what size child can use which particular seat and every seat must have a rule that includes age, weight, or height requirements for use of that model. North Carolina law says that it is legal to use any federally approved car seat as long as the child meets the requirements specified by the manufacturer for that seat.  Well, that does not really help with explaining what the proper way to use the car seat is! Since the laws vary from state to state, most car seat manufactures do not specify use other than stating what the height/weight/age, etc., requirements are; so, let’s go further into proper use and positioning of car seats.  

General Information: 

  • In general, ensure that the car seat: 
    • Is installed in the correct direction for the age and size of the child 
    • Is installed at the recline angle allowed by the manufacturer – refer to the car seat’s instructions and recline angle indicators (if equipped) 
    • Is installed in the rear seat – the center rear seat is generally considered to be the safest seat in a car because it is the farthest seat from any potential impact, but the side seats also provide good protection and may make it easier to get the child in and out of the car 
    • Is installed with the seat belt or LATCH attachments threaded through the correct belt path on the car seat 
    • Is installed tightly such that there is less than 1 inch of movement side to side and front to back when checked at the base of the seat at the belt path (where the seat belt or LATCH attachments are located). 


The Child Must Be Buckled Correctly Into the Car Seat According To The Manufacturer’s Instructions (The following are general guidelines. Consult your car seat owner’s manual for instructions specific to your seat): 

  • Harness Strap Positioning: When harnessing your child in a car seat, be sure that the harness is in the correct position. Unless instructed otherwise by the car seat manufacturer:  
    • Position the harness at or below the shoulder for a rear-facing seat 
    • Position the harness at or above the shoulders for a forward-facing car seat. Some convertible car seats require that the top position always be used when the seat is forward-facing. Always consult your car seat owner’s manual to determine the correct harness position for your specific car seat.  
  • Harness Adjustment: A snug harness is important for good crash protection, but it should not cause discomfort to the child.  
    • To determine if the harness is snug enough, tighten the straps using the harness adjustment mechanism on the seat. Then, try to grab a pinch of the harness at the child’s collarbone/shoulder area. If you can pinch up some of the harness, it is too loose.  
    • On many seats, extra harness slack can gather in the hip area. 
    • Once the harness is adjusted, position the harness clip at armpit level. This clip is designed to hold the harness straps in place on the child’s shoulders.  
    • In rear-facing seats, most manufacturers allow you to use a rolled diaper or washcloth to take up space between the baby and the crotch strap to prevent slouching. Similarly, you can add rolled up receiving blankets to the sides of the seat in order to position an infant. These should only be added after the child has already been buckled into the seat. Never put anything behind the child’s head or body that was not provided by the car seat manufacturers specifically for that purpose.  


Position chest clip

Position the chest clip at armpit level 

Photo Credit: NHTSA 

Appropriate Clothing: 

  • Make sure your child is wearing clothes that allow for a proper fit of the harness. 
  • Thick puffy jackets/coats and other bulky clothes can affect how the harness fits on the child and may interfere with how the harness works.  
  • In cold weather, either dress your child in non-bulky clothes such as a fleece jacket or remove any puffy jackets prior to buckling your child into the car seat. Keep a blanket in the car and tuck it around the child once the harness has been fastened and adjusted.  

 Appropriate clothing

Child wearing non-bulky clothing 

Photo Credit: NHTSA 

Rear-Facing Seats: 

  • Use rear-facing child restraints (either a rear-facing-only seat or convertible seat) for children until at least 2 years of age OR until they reach the maximum height or weight allowed by the car seat manufacturer 
  • Most rear-facing child restraints available today can accommodate children rear-facing up to 30 pounds or more (depending on the model) which is why it is important to know the requirements for your particular brand and model.  
  • **For Optimal Protection, Children Should Remain Rear-Facing As Long As Possible** 

Rear facing only Rear facing convertible 

Infant in Rear-Facing-Only Car Seat; Child in Rear-Facing Convertible Car Seat 

Photo Credit: NHTSA 




  • For optimal protection children should remain rear-facing until they reach the maximum height or weight limit allowed by the car seat manufacturer.  
  • When children outgrow their rear-facing seats (by weight or height, whichever comes first) they should ride in forward-facing car seats with harnesses until they reach the upper weight or height limit of the seat.  
  • The upper limits can range from 40 to 90pounds, depending on the model.  


Forward facing seat with harness

Eli Meir Kaplan for Home Front Communications
National Highway Traffic Safety Administration

Child in Forward-Facing car seat 

Photo Credit: NHTSA 


Booster Seats: 

  • Resist the temptation to put a large but young and behaviorally-immature child into a booster seat. Instead, consider a combination seat with a higher upper weight limit (also called a harnessed booster seat) that has a harness that can be removed when the child is mature enough for a booster seat. 
  • Once the forward-facing harness is outgrown by height or weight and the child is mature enough to leave the seat belt properly positioned on them in the booster seat, children should use a belt-positioning booster seat until the lap and shoulder belts fit properly on their own (it will be mentioned later how to know when the belts fit properly) 
  • Booster seats work by boosting up the child so that the seat belt fits properly. The seat belt does all the work, the booster seat just helps to put the seat belt in the right place.  
  • The shoulder belt should never be tucked under the arm or behind the back 
  • Booster seats can only be used with a lap and shoulder belt 
  • Children should continue using a belt-positioning booster seat until the vehicle’s lap and shoulder belts fit correctly on its own. For most kids, this won’t be until they are between 8 and 12 years old (This is a big age range! My nine year old is tall for his age but he is still in a booster seat because he is not 80 pounds and the shoulder harness does not go across him yet at the proper position) 

 Backless booster Highback booster

Child in a Backless Booster Seat; Child in a Highback Booster Seat 

Photo Credit: NHTSA 


Seat Belts: 

  • Again, the age range is large for when a child is ready to sit with a seat belt. Age should not be the only deciding factor. 
  • A properly-fitted lap belt fits low and snug across the hips and should be at least touching the upper thighs. A properly-fitted shoulder belt is positioned across the collarbone and chest.  
  • In an accident, the seat belt can cause injury to the child if incorrectly positioned (think about the injuries the child would sustain if the belt was across their neck vs. across their collarbone) 


Seat belt

Eli Meir Kaplan for Home Front Communications
National Highway Traffic Safety Administration

Older Child using Seat Belt 

Photo Credit: NHTSA 


North Carolina Law: 

  • North Carolina law does not allow the use of just the seat belt until the child is at least 8 years of age or at least 80 pounds, even if it looks like the seat belts fits. (This is where parents get confused and think, “Now that my child is 8 years old, he doesn’t have to ride in a booster seat,” which is untrue.) 
  • When a child reaches age 8 (regardless of weight) or 80 pounds (regardless of age)  they are eligible (permitted/allowed) to ride in the car using only a seat belt (without a booster seat) if it fits properly. 
  • There’s no magic number. Kids need a booster seat until the seatbelt fits properly without it 
  • Some kids may be able to pass the “seat belt fit test” on their 8th birthday and others will need more time to grow before the seat belt fits correctly. If the seat belt does not fit correctly, the child still needs a booster seat.  

How do we determine if the seat belt fits correctly? 

  • Kids come in all shapes and sizes, so every child’s safety needs are a little bit different 
  • The following are tips to help figure out what “fits correctly” means for your child: 
    • Sit tall and bend knees: the child should be able to sit with their bottom against the back of the seat and their knees bent at the front edge of the seat.  
    • Children whose knees do not bend at the front edge of the vehicle seat will likely end up slouching down until their knees bend and they are more comfortable. When this happens, the seat belt will come off the hip bones and onto the stomach area.  
    • Children whose knees do not bend at the edge of the vehicle seat need a booster seat.  


    • Shoulder: the shoulder belt crosses mid-shoulder – not too close to the neck and not too close to the arm.  
    • The shoulder belt helps keep the upper body in place during a crash. Without the protection of the shoulder belt, the upper body can move too far forward during a crash. When this happens the head may strike whatever is in front of it (the back of the front seat or vehicle dashboard depending on where you are sitting), potentially causing significant injuries.  
    • If the shoulder belt rubs the neck, it is very uncomfortable. If the shoulder belt is too close to the arm, it could slide off the shoulder, giving less protection. 
    • Hips: The lap belt crosses the body on the upper thigh/hip area – not the stomach 
    • The position of the lap belt is especially important and is often overlooked. It is important that the lap belt crosses the strong hip bones. In a crash, your bones will help protect you from injury. 
    • If your child is not big enough to use the seat belt alone, the lap belt will be on the stomach instead of the hip bones; and in a crash, the child could be seriously injured when the lap belt digs into the stomach. 



Picture Examples of Correct and Incorrect Seat Belt Use:  


North Carolina Laws, Continued:  

  • Children who are less than age 5 and less than 40 pounds must be restrained in the back seat if the vehicle has a passenger side front airbag and has a rear seat.  
  • Booster seats can only be used with lap and shoulder seat belts. They can NEVER be used with a lap belt only. A child who weighs at least 40 pounds can legally be restrained using only a properly-fitted lap belt if there is no lap and shoulder belt available for use; however, this is not considered to be the safest option. 
  • All drivers and passengers age 16 year and older must wear their seat belts in both the front and back seats. Children less than age 16 should follow the child passenger safety law (above).  
  • Children less than age 16 are prohibited from riding in open beds of pickup trucks or other open cargo areas without permanent overhead restraining construction.  
  • There is not a law stating what age a child is able to ride in the front seat, but the American Academy of Pediatrics and other safety organizations suggest leaving children in the back seats until they are 12 or 13 years of age. 
  • Rear-facing car seats cannot be installed in front of an active airbag (i.e. the front seat).  The child could be seriously injured or killed if there is a crash and the airbag deploys. 
  • In NC it is legal, though not necessarily recommended, for a child to ride in the front seat if any of the following apply: 
    • The vehicle has no front passenger air bag 
    • The vehicle has a front passenger air bag that is turned off with an on/off switch 
    • The vehicle has no rear seat 
    • The child is 5 years or older 
    • The child weighs 40 pounds or more 


This was a lot of information and I apologize for that and the length of the blog, but this I hope will serve as a go-to guide for parents when they have any questions about car seats and the laws here in North Carolina. As always, if you have any further questions or concerns, please speak with your child’s provider and they will gladly help.  


North Carolina Child Passenger Safety Law. (2018). Retrieved July 11, 2018 from ,

Cover photo credit: Steven Depolo

Written By: Christopher Elkins, CPNP Practitioner Elkins was born and raised in Chapel Hill, North Carolina. He is a board certified Pediatric Nurse Practitioner by the PNCB (Pediatric Nursing Certification Board). He sees patients from birth to 21 years of age. Christopher and his wife Erin have an 8-year-old son, Everett. Christopher and his family enjoy traveling to the mountains of North Carolina in the fall; enjoy the beaches during the summer, and concert-going all year round.

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