Introduction The objectives of this study were to investigate the level of awareness and usage of child car seats in Pakistan, identify problems that influence non-usage among the knowledgeable parents, as well as to explore the need and interventions for conducting effective awareness campaigns or educational programs for parents in the country. Methods Total 375 vehicles with children occupants and 622 children were observed at several schools, day-care centers, pediatric departments in hospitals, and children recreational places within 3 cities of Pakistan. Child safety restraints usage was almost negligible in the study sample. Out of the total 375 vehicles, 318 parents/drivers participated in the interview survey. Results Almost half of the participants were found to be unaware of child car safety restraints. Those who knew, most commonly expressed unavailability, time taken in child car seat installation, and absence of law as the reasons behind not using the child car seats while another common reason was their misperception about the children age group for using child car seats. Driver's education level was found to be the most significant (p < 0.0001) demographic characteristic associated with the driver's awareness on child car seats as well as support towards their usage, initiation of awareness campaigns, and law implementation. Conclusions The findings of the study indicate a great need and potential for child car seat educational programs as well as market for such devices especially among educated and affluent parents. The findings of the study also identify parents’ behaviors and attitudes, existing problems, and highlight several challenges and recommendations for planners, policy makers, transportation safety specialists, pediatricians, law enforcement agencies, as well as manufacturers for promoting children road safety.@en