When Should My Child Transition From Rear-Facing To Forward-Facing In The Car?

Most baby milestones excite parents, while simultaneously making life just a little more complicated. Without a doubt, though, your baby or toddler reaching the weight/height/age to warrant graduating to a forward-­‐facing car seat makes things easier on everyone. A forward-­‐facing child is easier to entertain, possibly less likely to get carsick, has more legroom, and is easier to see from the driver’s seat. A forward-­‐facing car seat takes up less room in the car. Car seat graduation is a definite win in terms of comfort and convenience. However, the American Academy of Pediatrics (AAP) has recently updated their recommendation (previously 1 year and 20 pounds) regarding forward-­‐facing readiness, and now suggests you leave your toddler facing the rear of the vehicle until age 2, or until they reach the maximum height and weight specified by the car seat manufacturer for rear-­ facing use. Because more and more car seats available in the U.S. are now offering greater rear-­‐facing weight limits, however, this statement by the AAP presents some decision-­‐making challenges.

The major dilemma associated with interpreting the AAP’s new guidelines is that some rear-­‐facing car seats, including those available from major national brands, now allow children up to 40 pounds to face backward. While height limits aren’t as clearly defined -­‐-­‐it’s not the total height of the child so much as it is the length of the torso plus the head that determines car seat fit -­‐-­‐ larger rear-­‐facing car seats allow an average-­‐height child to ride safely well past their second birthday. Since the average (50th percentile) two-­‐year-­‐old boy weighs somewhat less than 30 pounds and the average two-­‐year-­‐old girl weighs just a bit less than her male counterpart, according to growth charts from the U.S. Centers for Disease Control and Prevention (CDC), the average two-­‐year-­‐old is still well within manufacturer weight limits for many rear-­‐facing seats. Even the average four-­‐year-­‐old weighs less than 40 pounds, according to those same growth charts, and at around 40 inches in height, the average four-­‐year-­‐old is also likely to fit into one of the newer rear-­‐facing seats. Does the AAP mean to suggest that you should turn your child around when they’re two, or when they outgrow the seat? This is a critical question, as there is clearly the potential for a major discrepancy between those points in time.

The new AAP recommendations are a little vague on which milestone takes precedence, which is probably intentional. The policy update is ostensibly in response to a study published in 2007 (Henary et al). The researchers found that (as expected) infants up to a year of age are considerably safer in a rear-­‐facing car seat than in a forward-­‐facing seat. They determined that the same is true of older babies and toddlers. The effectiveness of a rear-­‐facing car seat (calculated as the percent of cases in which its proper use prevented serious injury in a crash) was 97.2% for infants under a year, while forward-­‐facing car seats were 93.7% effective at preventing serious injury. Among 12-­‐ to 23-­‐month-­‐olds, rear-­‐facing seats were also more effective at preventing injury (86.2%), compared to forward-­‐facing seats (69.3%), though neither seat was as effective in the older age group as it was in the younger. Because the discrepancy between forward-­‐facing and rear-­‐facing effectiveness is greater for 12-­‐ to 23-­‐month-­‐olds, these data suggest that the rear-­facing orientation is actually more important for toddlers than it is for the youngest babies.

While the AAP’s press release suggests that the new recommendations are in response to “new research,” the reality is that many studies have demonstrated the safety of rear-­facing over forward-­facing car seats. In fact, the findings of the Henary study closely mirror those collected from Volvo’s Swedish accident database and reported in 1997 (Isaksson-­‐Hellman et al). Several other analyses of accident databases and collision studies using dummies have found the same (e.g., Sherwood et al, Anund et al, Emam et al).

Accident database analyses and crash-­‐test dummy data don’t just support the use of rear-­‐facing car seats up to 23 months of age, however -­‐-­‐ they actually support the rearward position up to age 4. While we’d all (adults included) be safer in a rear-­‐ facing seat in the event of a crash because the position helps to spread the impact over a larger portion of the body, babies and young children are particularly susceptible to injury in the forward-­‐facing position because of their proportionally large heads. For this very reason, children ride rear-­‐facing until 4 years of age in many European countries.

Parents may worry about the comfort or safety of an older child, given the limited legroom available in a rear-­‐facing seat. While there are no published data comparing leg injuries in rear-­‐facing and forward-­‐facing seats, the forward-­‐facing position doesn’t spare the legs in a crash. Leg injuries are common and can be severe in forward-­‐facing positions (Bennett et al). Further, however, even a severe leg injury is more reparable and less likely to be life threatening than a head or neck injury, and these are far more likely in the forward-­‐facing position. As to the matter of comfort, no studies have yet compared motion sickness rates in rear-­‐ and forward-­‐ facing passengers, but children are generally more comfortable with their legs bent than are adults, due to the greater flexibility of a child. Further, the sheer number of European children riding rear-­‐facing for extended periods (up to 75% of Swedish children ride rear-­‐facing through their 3rd birthday [Anund et al]) suggests that comfort issues -­‐-­‐ if they exist -­‐-­‐ aren’t sufficient to motivate parents to turn their children around prematurely.

There are differences between the U.S. and Europe, of course, the most notable of which is that many sprawling U.S. cities necessitate longer driving times, and the scale of cross-­‐country car travel is much greater. This means that practical considerations -­‐-­‐ including the ability to interact with a child and the reduced cargo space afforded by a rear-­‐facing seat -­‐-­‐ may be of greater significance in the U.S. Then, too, there are the questions that haven’t been (and perhaps can’t be) answered by examining crash databases. These include whether a toddler or young child is less likely to cry if forward-­‐facing, and whether a parent’s driving ability is negatively impacted by a screaming or crying child. Effectiveness of the seat orientation non-­‐withstanding, if turning a toddler to face the front of the car keeps them amused and quiet, that could be an important safety consideration.

In the end, the AAP’s new car seat guidelines seem to be a compromise between what the data support (rear-­‐facing until age 4) and what parents need (forward-­‐ facing as soon as possible). Still, they’re guidelines -­‐-­‐ not laws -­‐-­‐ so parents are free to make the decision that works best given their car, their car seat, and their child.

Science Bottom Line:* Evidence supports leaving a child rear-­‐facing as long as possible (i.e., beyond age 2), within the weight and height limits of the car seat. Evidence further supports purchasing a car seat with the maximum available rear-­‐ facing weight and height limits.
When did you or will you turn your child around in the car?

 

References:

American Academy of Pediatrics Recommendation on Car Seats. Accessed 21 Sept 2011.

Bennett et al. Crash analysis of lower extremity injuries in children restrained in forward-­‐facing car seats during front and rear impacts. J Trauma. 2006 Sep;61(3):592-­‐7.

Anund et al. Child safety in cars-­‐-­‐literature review. (VTI report 489A.) Linköping: Swedish National Road and Transport Research Institute, 2003.

Emam et al. A study of injury parameters for rearward and forward facing 3-­‐year-­‐ old child dummy using numerical simulation. International Journal of Crashworthiness 2005;10:211-­‐22. ExternalResolverBasic [Context Link]

Henary et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007 Dec;13(6):398-­‐402.

Isaksson-­‐Hellman et al. Trends and effects of child restraint systems based on Volvo’s Swedish accident database. (Report No SAE 973299.) In: Proceedings of Child Occupant Protection 2nd Symposium. Warrendale, PA: Society of Automotive Engineers, 1997:43-­‐54.

Sherwood et al. Frontal sled tests comparing rear and forward facing child restraints with 1-­‐3 year old dummies. Annu Proc Assoc Adv Automot Med 2007;51:169-­‐80.

U.S. Centers for Disease Control and Prevention Clinical Growth Charts. Accessed 21 Sept 2011.

Watson et al. Advise use of rear facing child car seats for children under 4 years old. BMJ. 2009 Jun 11;338:b1994.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

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5 Comments (+add yours?)

  1. Jem
    Sep 27, 2011 @ 07:46:13

    Great summary. We also decided to carry on rear-facing for as long as possible based on similar evidence.

    Re: car-seat screamer – have you tried fixing a mirror (coated plastic, obviously) to the back seat? This will give your little passenger something to look at, greater view etc. Worked here, until ours was tall enough to be able to look out of the window.

    Reply

    • SquintMom
      Sep 27, 2011 @ 22:17:50

      Thank you for the suggestion…we've tried it with limited luck. The best fix seems to be having someone ride in the back seat with her; she enjoys having her very own entertainment committee!

      Reply

  2. Catherine McCormack
    Oct 12, 2011 @ 05:58:32

    Both my kids were car seat screamers. In Ella’s case it was unbelievably extreme. Driving her anywhere, even a 10 minute trip to the shops was like listening to her having her fingernails pulled out. They were the same in prams and high chairs and anything with a strap actually…but the car seats were the worst. I tried everything from mirrors to music to toys. The only thing that we any vague success with was an in car DVD player. As a result I turned them both way too early and just tried my best not to drive with them unless I absolutely had to. The alternative resulted in me having a (minor) car crash and was simply too traumatic for all concerned. They are now just over 3 and 1. I tried Ethan in his rear facing seat the other day and he looked like he was crammed in and as far as I know we don’t have toddler-sized rear facing seats in SA.

    Reply

  3. Trackback: Updated Policy on LATCH Use For Securing Car Seats | SquintMom.com
  4. Gillian
    Jul 06, 2012 @ 18:33:51

    My daughter is 2 years and 5 months old. She’s been right around the 50th percentile for length/height and weight since I was 19 weeks pregnant. She’s currently 28 lbs, and 34″ tall.

    She still happily rear-faces. I’m planning to keep her rear-facing until the limit of her seat (40 lbs), unless some unforeseen issue comes up that necessitates re-evaluating that plan.

    I also wanted to comment on the comfort of kids’ legs while rear-facing. Not only are kids more comfortable with their legs bent than adults are, but the pressure of dangling one’s legs over the bottom edge of the carseat, as a forward-facing toddler does, may cause more discomfort by putting pressure on nerves in the back of the legs or cutting off circulation. A rear-facing toddler with her legs bent doesn’t experience that discomfort.

    Reply

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