Age-related decline in appropriate child restraint use during transport to healthcare facilities

To evaluate child restraint use during transport to healthcare facilities and to identify age-related patterns and determinants of inappropriate restraint use.

A cross-sectional study, it included 502 caregivers of children aged 0-17 years presenting to a pediatric emergency department or outpatient clinic in Portugal between May 2025 and January 2026. Data were collected using a structured questionnaire. Restraint appropriateness was classified using a predefined algorithm aligned with United Nations Economic Commission for Europe (UNECE) Regulations No. 44 and No. 129. Associations were assessed using univariable analyses and multivariable logistic regression.

Overall, 72.9% of transports were classified as appropriate and 27.1% as inappropriate. Appropriate child restraint use declined significantly with age, reaching its lowest levels among children aged 9-12  years, in whom more than half of transports were inappropriate (p < 0.001). Self-reported familiarity with child transport legislation was high (85.1%), although objective knowledge of specific safety criteria was substantially lower and was not independently associated with transport appropriateness. Absence of prior professional guidance (OR 1.94, 95% CI 1.20-3.11) and uncertainty regarding prior guidance (OR 3.85, 95% CI 1.60-9.25) were independently associated with inappropriate child restraint use.

Inappropriate child restraint use during transport to healthcare facilities is common and shows a marked age-related decline. These findings identify middle childhood as a vulnerable period and support the integration of structured child passenger safety counseling into routine healthcare.