Testing Child Restraint Devices for Ambulances

On March 9, 2023, NASEMSO began a 15-month project (Method for Testing Child Restraint Devices in Ground Ambulances), funded by the National Traffic Highway Safety Administration (NHTSA) Office of Emergency Medical Services (OEMS), which will take the critical, initial steps to improve the safety of children transported by ambulance.

Method for Testing Child Restraint Devices in Ground Ambulances Project Overview

This 15-month project (March 2023-June 2024) will focus on drafting crash test methodology intended to evaluate the safety of commercially available devices used to secure children in the back of an ambulance. Test methods will be drafted for three unique transport situations:

  1. supine pediatric patients (i.e., laying on their back on an adult sized cot);
  2. seated pediatric patients or child passengers; and
  3. supine neonatal patients.

2016 ambulance crash in Albuquerque, NM, involving an infant ejected from an incubator. NHTSA’s crash investigation report is available here.

This project is the first phase of a three-step process to develop, validate, and publish these three new child restraint test methods. This project will be completed collaboratively with industry experts (product manufacturers and ambulance builders), emergency medical service (EMS) clinicians, crash test laboratories, and federal and state partners. Three workgroups are being formed to draft the test methods for each of the above transport situations. Once the test methods have been drafted, NASEMSO hopes to support the next phase of the project: crash testing of pediatric restraint devices currently available in the U.S. market. When funded, the crash testing phase will be used to both validate the draft test methods and evaluate existing and newly designed pediatric transport products.

The Technical Project Lead is Jim Green, who recently retired from his role on a related multi-year research project at the National Institute for Occupational Safety and Health (NIOSH). The NIOSH-led collaborative project drove dramatic improvements in EMS clinician and adult patient ambulance crash safety. Green will utilize a similar approach in the effort to improve child safety in ground ambulances. NASEMSO support is provided by Rachael Alter (Project Manager) and Adrienne Wilson (Project Coordinator).

For more information, contact NASEMSO Program Manager Rachael Alter at

With ambulance crash rates at least 2.5 times greater than that of an automobile 1, and an average of 841,000 children transported in ambulances annually in the United States 2, development and testing of crashworthy pediatric restraint devices for ambulances is long overdue.

From 2003 – 2017, federal research led to dramatic improvements in EMS clinician and adult patient safety when involved in an ambulance crash. These efforts resulted in the publication of ten new standards covering key components such as EMS clinician seating, patient cot and cot retention system, cabinets, equipment mounts, and the ambulance body structure. These documents have been embraced by national standard setting bodies and state EMS regulators. Unfortunately, the safe transport of children (neonates, infants, toddlers, pre-teens) has not been addressed by any of these standards .

1 Centers for Disease Control and Prevention (CDC). Ambulance Crash-Related Injuries Among Emergency Medical Services Workers, United States, 1991-2002. MMWR Morb Mort Wkly Rep. 2003;52(08):154-6.
2National Emergency Medical Services Information System, Version 3 Data Cube. Accessed August 9, 2021. Data from 2019 and 2020 for children 13 and younger.

Without standards, state regulators and purchasers have no way to distinguish high-quality, safe, pediatric transport devices from those that are inadequate or even dangerous. 

Just as there are specific standards for both child car and booster seats in a personal vehicle, standards are necessary to ensure the safety of devices used to transport children in ambulances, as children simply cannot be secured safely on an adult cot. Due to the unique transport needs of the pediatric population, NASEMSO, along with national experts, recommends the creation of pediatric transport standards, which would address three ambulance transport scenarios based on patient size, illness and/or injury.

What can be done?

Thanks to the support from NHTSA OEMS, the Method for Testing Child Restraint Devices in Ground Ambulances project is the first step of a three-phrase process to develop (phase 1), validate (phase 2), and publish (phase 3) child restraint test methods. We expect the active participation of ambulance manufacturers and their suppliers, pediatric transport device manufacturers, pediatric transport experts, EMS clinicians, and key government officials throughout this first phase.

Completion of all three phases of this project is expected to last approximately 5 years.

How long until the test methods are published for state adoption?

We anticipate this to be a five-year effort that includes development of three test methods (phase 1, year 1), validation testing to refine and most importantly validate the soundness of the test method (phase 2, years 2 and 3), and finally publication and adoption (phase 3, years 4 and 5).  More than 50% of the cost of this effort will be consumed during the full-scale test validation process (e.g. repeated testing at crash test facilities).

Why can’t we use the adult standards and restraints?

The restraints used to secure an adult on a cot are simply too large to adequately restrain a child, just as adult automobile restraints are too large to safely restrain a child in a car.  Given the size of a pediatric patient, specialty restraint systems or devices are required.  These specialty restraint systems and devices will require unique testing protocols and pass/fail criteria, just as pediatric automobile seats require unique testing methods, test dummies, and pass/fail criteria.

Why weren’t pediatric patients included in the original adult standards?

The original standard development program was focused on EMS clinician safety during a crash. The testing focused on improving worker seating and requiring robust medical equipment mounts and secure cabinets to limit flying equipment and supplies.

Why can’t we use personal vehicle car seat or booster seat standards?

Traditional car seats are anchored and tested on a fixed forward-facing seat to simulate the back-seating area of an automobile.  Such seat and anchor systems do not exist in an ambulance. In fact, child car seat manufacturers have specifically recommended against using their devices in an ambulance for this reason.  In addition, if an automobile car seat were used, it would limit the ability of the EMS clinician to provide medical assistance to the pediatric patient.

How will product manufacturers participate?

Product manufacturers have agreed to participate on the standards development committees and to design and manufacture new, more robust products, as in-kind contributions to the effort.   By the end of the effort, each manufacturer should have a product available that has been tested and meets a new standard.  Through this process we will be able to accelerate the introduction of new, safer products to market.

 Why do we have to test to develop new standards?

Testing is the process used to prove the new standard is written clearly and can be effectively used to evaluate the strength of each pediatric transport device.  Without testing or “proving” the new standard to be useful and effective, we will not be able to achieve consensus nor will we be able to have the standard published by an accredited standards development organization.

Who would publish these standards?

We propose that these three new test methods be published by the Society of Automotive Engineers (SAE). The SAE published the original ten test methods described earlier. The SAE is aware of this project and has indicated interest in working with NASEMSO.

What would be the end result of this project?

At the conclusion of this collaborative, cost-sharing effort, the project team should have a minimum of three new published test standards (patient transport modes listed above) and industry partners will have designed and tested new, safe, and more robust pediatric transport devices. Once each test method is published, manufacturers will be able to advertise that the products they have developed and tested meet a specific, industry accepted minimum testing requirement. Manufacturer test results, derived from the new consensus test methods, may then be used comparatively by prospective purchasers both nationally and internationally, as they strive to provide safe and effective transport options for their pediatric patients.


For more information, please read: NASEMSO Safe Transport of Children in Ambulances Project Executive Summary

NASEMSO contact:

Rachael Alter, BA
Program Manager