Several years ago, on March 21, 2011, the American Academy of Pediatrics (AAP) issued a policy statement on child passenger safety. The first, of the five evidenced-based recommendations for best practices to improve safety in passenger vehicles from birth through adolescence, is specifically on rear-facing child safety seats (CSS). Whereas this first AAP recommendation, recommends that:
What has continued to change since the publication of this policy statement, that can improve the efficacy of this recommendation, is that car seat manufacturers are now designing car seats with increased weight and height limitations so children can ride rear-facing longer. Unfortunately too many children are still being placed forward-facing prematurely. Nearly all convertible car seats (those that are rear-facing then convert to forward-facing) have rear-facing weight limitations of 40, 45, and even up to 50-pounds (keep in mind children generally reach height before weight). This means that children can ride rear-facing on average up to 3-5 years of age (based upon CDC Clinical Growth Charts of height and weight by age).

While age milestones are helpful to educate parents, pediatricians should also keep in mind that parents are more likely to remember only the first part of the AAP recommendation of "Rear-Facing...Until They Are 2 Years of Age" rather than the later part "or Until They Reach the Highest Weight or Height" of their car seat. By remembering "2-years", parents are more likely to turn their child at their second birthday, instead of keeping the child rear-facing to the upper weight or height of the car seat.

As an example, as an injury and neuroepidemiologist, as well as a Certified Child Passenger Safety Technician (CPST) and Master of Certified Health Education Specialist (MCHES), upon conducting a 24-month study (June 2014-June 2016), educating 2,020 individual expectant parents on how to install and use their car seats, based upon a pre-education questionnaire, 97% reported that at 2-years of age is when they should turn their child in the forward-facing position in their car seat. Further, 92% reported they felt it is safe to place their child in a forward-facing position.  In a separate dataset over the same study period, 8,760 phone consultations and inquiries were received on child passenger safety from both expectant and existing parents. Of these, 2,375 were from existing parents who had children between the age of 12-24 months.  Eighty-seven percent of these parents inquired about turning their child's car seat from rear-facing to forward-facing because their child was turning 2-years of age. Further, only 6% of these parents acknowledged that it is safer to keep their child rear-facing as long as possible (over 2-years to weight of their car seat).

It is important to also note that all car seats are crash tested at different height and weight for rear-facing and forward-facing. Because children generally reach the height before weight, it is also helpful for pediatricians to keep in mind when discussing, keeping children at each stage longer, especially with rear-facing, to remind parents it is vital to follow the recommendations of both the height and weight requirements printed on the side of their car seat (Figure 1 provides an example). 
Figure-1: The importance of following instructions of both height and weight of the car seat.

The ability of child passengers to be rear-facing in car seats has continued to change rapidly over the past recent years. With these changes, new expectant parents, who receive well intended advice from family, recently new parents and friends, can be at risk of following no-longer recommended practices from only a several years ago. Further at risk, are also those parents having a second child who might use their past practices, that were the best practice recommendation for their first child, but might no longer be recommended (i.e. 12-months forward facing for example). This is where pediatricians can help remind parents on the entire AAP recommendation and to remind parents, that because car seats are being designed at higher weight limitations of 40, 45 and even 50-pounds, it is possible for children to now remain rear-facing to even 3-5 years of age (keep in mind that generally reach height before weight). So parents should keep their child rear-facing up to the height or weight printed on the side of their car seat. Further, regarding pediatrician recommendations, 98% of the 2,020 expectant parents among the Pro Consumer Safety study, chose their pediatrician as the most common source of child passenger safety advise. Similarly, a National Poll on Children's Health also found that physicians were the most common source of information for parents regarding changing their child to a forward-facing position.

The concept of children riding rear-facing is not new. The history of children riding rear-facing began in the early 1960's by Professor Bertil Alman of Chalmers Univeristy in Gothenburn, Sweden. He became inspired how astronauts used rear-facing seating to protect their head, neck and spine. As a result he designed the first rear-facing child car seat in 1963 and by 1965 children in Sweden were riding in rear-facing to 4-years of age. Since then Sweden has nearly eliminated motor vehicle fatalities and severe injuries among children younger than 5 years of age.

While the United States has a long way to go to catch up with Sweden. However with the Federal Highway Administration, National Strategy on Highway Safety "Toward Zero Deaths", this is a step in the right direction. Further, among the child passenger safety industry, with newer car seats now designed for higher weight for rear-facing, the United States can be on the path to finally catching up. However even though motor vehicle fatalities have gone down in the United States, child motor vehicle fatalities and misuse of child restraint systems (car seats) are still high. So much more is needed to educate parents on proper installation and use. With effective education, training and practical skills provided to parents on child passenger safety, this eventually can help change the culture of rear-facing. Whereas children in motor vehicles ride rear-facing up to 3-5 years of age is just the norm.

 While the AAP and American Congress of Obstetricians and Gynecologists (ACOG) both have excellent recommendations for parents on child passenger safety and occupant protection, studies have shown that new parents count on pediatricians and other healthcare practitioners to provide car seat and motor vehicle safety information to them. To help in this effort, Pro Consumer Safety also has Pediatric Injury Prevention Services and even Health Education Resource materials that can be downloaded, printed and distributed to parents.
Safety guidelines & resources for parents:
  • Keep your child rear-facing up to the maximum height or weight printed on the side of the car seat (see why rear-facing longer)
  • For infants who have outgrown their rear-facing only car seat (base and car seat carrier that also goes into a stroller), they can move into a convertible seat to be rear-facing longer.
  • Among most convertible car seats the child can be rear-facing between the age of 3-5 (depending on height or weight requirements on car seat). Even if the child's feet are up onto the back of the vehicle seat, it is best to keep their head and neck protected.
  • When shopping for a convertible car seat, choose one that has the highest weight maximum. Also make sure it is compatible to your vehicle so it can be installed correctly, both rear and forward facing. The car seat must be able to be installed correctly, at the appropriate level, while having sufficient space between the back of the car seat and back of the front vehicle seat when rear-facing to allow for the ride-down-effect of a crash. There also needs to be sufficient space for the passenger and driver to ride safely (knees no close than 3-inches to the dashboard and driver no closer than 10-inches to the steering wheel and passenger no closer than 20-inchest to the airbag).
  • Never rush to advance your child to the forward-facing stage. The moment you turn your child forward-facing, during a motor vehicle collision the child is an increased risk of head, brain and neck injury.
  • Always have a Certified Child Passenger Safety Technician make sure you have the most compatible car seat for your child and vehicle, and to make sure you know how to install, test and reinstall the car seat on your own.
  • New parents can follow Baby Growth Charts & Best Practices Car Seat Stages (Download material: Baby Growth Charts and Stages of Buckling Up).
  • See upcoming January 1, 2017 new rear-facing California Law, but with new seats, children can remain rear-facing longer (Download material).
  • Keep the "Chest Clip" level with the child's armpits (Download material).

Other Car Seat Safety Resources:
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Physicians and other healthcare professionals, remember to explain to new parents, that infants and toddlers should ride in a rear-facing car seat until they are 2 year of age, but with newer car seats, with increased weight maximum, they can now ride rear-facing longer usually between the ages of 3-5 years depending on the weight and height printed on the side of the car seat.
Questions and more information, please contact me or email at pediatriciansupport@proconsumersafety.com
 


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    Pro Consumer Safety

    Pro Consumer Safety provides  consumers with awareness on the risk of injury from the use of particular products and provides prevention to reduce exposure to injury risk and promote healthy lifestyles to families. Pro Consumer Safety also provides professional support services to pediatricians in an effort to increase awareness on injury prevention, and to provide evidenced-based health education materials and services for their patients.
         
    James DeCarli, founder and CEO of Pro Consumer Safety, is an injury and neuroepidemiologist, a
    Master Certified Health Education Specialist, Certified Child Passenger Safety Technician and a father. He is a public health professional with over 15 years experience developing, evaluating and implementing injury and violence prevention programs to governmental agencies, schools and hospitals.  
         He has graduate education in public health, neuroscience, public policy and intergovernmental management, from the University of Oxford, England, George Washington University, Washington D.C., and the University of Southern California. Among his efforts in injury and violence prevention he has established a multidisciplinary approach to educate not only the public as a community benefit but also to develop sustainable public health injury prevention programs to state and local governments, schools, hospitals and organizations to help promote safety and healthy lifestyles.
      He has held several leadership positions, as well as leads professional trainings, provides media advisories and appeared as a regular guest LaFern Cusack on the ESPN Experience (AM710) and Radio Disney Playground (AM1110).
      For health education and materials pediatricians and physicians can visit Pediatric Injury Prevention Services and Resources page.
       Contact me to discuss any child safety question, speaking engagements, or to request a discuss of a specific injury topic at jdecarli@proconsumersafety.com
     

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