When good intentions make bad policy – car seat edition

I recently got into a heated argument with a colleague over the use of car seats on an airplane. She felt that they should be mandatory for small children; I disagreed.

You see (for those of you who don’t have kids), up until a child is two years old, you can choose to have them ride in your lap instead of buying them their own seat. While this may seem uncomfortable for many, I know of any number of people (including yours truly) who have flown holding an infant in their laps. When our first child was born, I was a fellow and my wife wasn’t working, so travelling to see family was a luxury. We couldn’t easily afford that extra ticket.

Around that time, the FAA was considering making it mandatory for children less than two years of age to be restrained in their own seats on airplanes. The American Academy of Pediatrics agreed with them, and issued a policy statement in November of 2001:

Occupant protection policies for children younger than 2 years on aircraft are inconsistent with all other national policies on safe transportation. Children younger than 2 years are not required to be restrained or secured on aircraft during takeoff, landing, and conditions of turbulence. They are permitted to be held on the lap of an adult. Preventable injuries and deaths have occurred in children younger than 2 years who were unrestrained inaircraft during survivable crashes and conditions of turbulence. The American Academy of Pediatrics recommends a mandatory federal requirement for restraint use for children on aircraft. The Academy further recommends that parents ensure that a seat is available for all children during aircraft transport and follow current recommendations for restraint use for all children. Physicians play a significant role in counseling families, advocating for public policy mandates, and encouraging technologic research that will improve protection of children in aircraft.

Let’s review. First of all, the AAP wanted the FAA to make it a mandatory requirement for children to be restrained on aircraft. They also wanted me, as a parent, to buy a seat for my child. Finally, they they informed me, as a pediatrician, that it was my duty to tell all of my patients’ parents about this.

I wasn’t too happy about that, for any number of reasons. I got why child safety seats are important in cars. After all, you are much more likely to walk away from a car crash if you are adequately restrained. But can the same be said about a plane crash? Really? There are other considerations as well. How effective would such a policy be? How much would it cost?

Luckily, some enterprising researchers* crunched the numbers. They performed an econometric analysis to see what would happen under such a policy. Here’s the first bit of awesomeness: the recommended policy would likely prevent about 0.4 child air crash deaths per year in the US. Got that? Less than one child’s life might be saved each year.

Now you may be thinking that it’s still worth it. After all, that child may be someone you know. There’s a problem, though. If you make people buy seats for their children, they may not be able to afford to fly. Instead, they might choose to drive. Driving is way more unsafe than flying. It’s so much more unsafe that it turned out this policy would increase the number of child deaths if somewhere between 5% to 10% of families decided to make the trip by car instead of plane. Of course, this calculation varied by the distance being driven, with longer trips incurring more car-related danger. But if the average trip was 400 miles, then if just 5% of families chose to drive instead of fly, this policy would result in an increase in child deaths.

Not so clear anymore is it?

Moreover, this doesn’t take into account the cost of the policy. Let’s say, for the point of argument, that no families whatsoever would convert to a roadtrip. That’s not realistic, but go with it for a second. This means that we’d actually save lives under the mandatory restraint policy. Let’s also stipulate that the average cost of the policy would be about $200 for a seat for each small child flying. Sound OK?

Under these simple and reasonable assumptions, the cost per each child death prevented would be $1.3 billion. If you want to be precise, it was calculated to be $1,283,594,063. For comparison, that’s about 33,000 times more per life-year saved than the policies that mandate restraints in cars. It’s also pretty much the most expensive injury prevention policy imaginable.

If you want to save some children’s lives, I’ve got plenty of ideas for you. None of them will cost in the billions of dollars per prevented death. Here’s a good one from just yesterday over at JAMA’s blog: remember to make sure your child is still using a booster seat when they are being carpooled in other people’s cars.

*Full disclosure: I know all of the authors of this study. One was even a director of my fellowship. Here’s the link to the paper, but it’s probably gated.

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