Infants in Airplanes: Safety Seats, Statistics, and Common Sense

Abstract & Commentary

Synopsis: Despite widespread debate and broad recommendations from professional organizations, careful risk and cost analyses do not support policies mandating the use of infant safety seats on commercial aircraft.

Source: Newman TB, et al. Effects and costs of requiring child-restraint systems for young children traveling on commercial airplanes. Arch Pediatr Adolesc Med. 2003;157: 969-974.

Would lives be saved at a reasonable cost if it were required that all infants be restrained in safety seats while on airplanes? Using carefully planned and explained assumptions and calculations, Newman and colleagues found that there would be about 0.4 (range from 0.05 to 1.6 depending on the specifics of the assumptions made) deaths of young children prevented each year in the United States by the use of restraint systems. However, it is postulated that the increased cost for airfare required for children, who would otherwise ride "free" in a companion’s lap, might stimulate some families to choose road travel, thus incurring greater risk of death in traffic accidents. The break-even point for which safety seat use would actually prevent overall deaths would be if 1% of children were diverted from air to car travel because of the cost or hassle of using safety seats onboard. If more than 1% of families responded to a safety seat requirement by choosing road over air travel, the legislation could actually promote more infant deaths.

But, what if no children were diverted from air to road travel? In that case, lives would be saved—at a cost. Estimating that the additional cost per child traveler for ticketing of the aircraft seat and for the safety seat was only $200 (a conservative underestimation), it would still cost about $43 million for each life-year saved and $1.3 billion for each life saved. Newman et al poignantly conclude by saying that: "Unless space for young children in restraint seats can be provided at low cost to families, with little or no diversion to automobile travel, a policy requiring restraint seat use could cause a net increase in deaths. Even excluding this possibility, the cost of the proposed policy per death prevented is high."

Comment by Philip R. Fischer, MD, DTM&H

Tragically, some children die a preventable death when they are incompletely restrained in crashing airplanes. In fact, it has been suggested that an American child’s life would be saved every 2 years by requiring the use of child restraint systems on aircraft. In 1995, the US Federal Aviation Administration (FAA) suggested that these saved lives might be costly. In fact, the FAA calculated that the increased cost of air travel, when ticketed seats would be needed for restrained children, would prompt enough children (likely 5-10%) to divert from air to road travel and that an additional 10 children would die each year due to automobile crashes.

Consumer advocates Ralph Nader and Wesley Smith wrote that the FAA position was "unreasonable on its face and ridiculous in its justification." Also disagreeing with the FAA calculations, the US National Transportation Safety Board has for 3 years wanted to mandate the use of safety seats for children traveling by air. Two years ago, the American Academy of Pediatrics acknowledged a lack of data about the risk of diverting air travelers to more dangerous road routes but urged a requirement for air safety systems anyway. The AAP said that "all children need their own seats on airplanes—and children under the age of 2 or weighing less than 40 pounds, should be securely fastened in child restraint seats on planes." Now, as the FAA is planning to implement a new regulation requiring children younger than 2 years to ride in approved child-restraint seats on airplanes, Newman et al finally provide convincing data that could serve as an evidence base from which to refute such legislation.

Karl Neumann, in some senses the "father of pediatric travel medicine," presented practical advice during the Pediatric Travel Symposium at the recent annual meeting of the American Society of Tropical Medicine and Hygiene in Philadelphia. He made several relevant comments as he discussed the safety of traveling by air. First, "safety is no accident." Families should prepare wisely for safe air travel. Second, children "are the only things on planes that are not restrained." We should want to keep children restrained appropriately. Finally, though, Neumann said "ground transportation is very much more dangerous" and noted that requiring safety seats could indeed increase overall childhood deaths.

So, what is a travel medicine practitioner to do? None of us wants to allow a child to die in a survivable airplane crash. We should encourage families traveling with children to appropriately restrain their children. For infants, this would involve using an FAA-approved restraint (and not all car seats are appropriate for airplanes) in a ticketed seat. Families deterred by the cost, however, should be reminded that even restrained car travel is riskier than unrestrained air travel; they should not increase a child’s risk by driving unnecessarily. However, if aircraft restraints are legislated we must study the outcomes of such legislation. If Newman’s statement proves to be correct, we should be willing to change the requirement later if, indeed, it seems that more children are dying. At the same time, we should not hesitate to implement readily available, simpler, proven cost-effective interventions (such as car seats, malaria prevention, and vaccination) without which many traveling children already are suffering and dying unnecessarily.

Dr. Fischer is Professor of Pediatrics, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN. 

Suggested Reading

1. American Academy of Pediatrics. Restraint use on aircraft. Pediatrics. 2001;108:1218-1221; and

2. Bishai D. Hearts and minds and child restraints in airplanes. Arch Pediatr Adolesc Med. 2003;157:953-954.

3. Neumann K. Practical preparation of pediatric patients for foreign travel. Symposium 49: Pediatric Travel Medicine, 52nd Annual Meeting of the American Society of Tropical Medicine and Hygiene, Philadelphia, December 6, 2003.