March 2011 This information is not for reproduction or distribution
What are the most important messages for parents? 1) The most important message is that children should ride properly restrained on every trip in every type of transportation, on the road or in the air.
2) Infants and toddlers under 2 should ride facing the rear of the vehicle, children should ride in forward-facing seats after outgrowing the rear-facing limits, and older children should ride in a belt-positioning booster seat after outgrowing the forward-facing limits. All passengers of any age should ride in a lap and shoulder seat belt once they have grown big enough for the seat belt to fit properly. All children should ride in the back seat until they are 13 years old.
3) Parents often look forward to transitioning from one stage to the next, but these transitions should generally be delayed until they’re necessary, when the child outgrows the limits for their current stage. Riding rear-facing protects children better than riding forward-facing, riding in a forward-facing seat with a harness protects them better than riding in a booster seat as long as they fit within the stated limits, and riding in a booster seat protects them better than a seat belt alone until the seat belt fits correctly.
How big of a problem are motor vehicle crashes? While the rate of deaths in motor vehicle crashes in kids under 16 has decreased substantially – 45% between 1997 and 2009 – it is still the leading cause of death for children ages 4 and above. Counting children and teens up to age 21, there are more than 5000 deaths each year. Furthermore, for each fatality there are an additional 400 children and youth who are injured seriously enough to require medical treatment.
What prompted the policy revision? Over time, large, well-designed research efforts have yielded a great deal of scientific evidence that wasn’t available when the previous policy was published in 2002. We know much more now about how effective safety restraints are in reducing deaths and injuries. Additionally, there have been major changes in the design of vehicles and car safety seats and many states have strengthened their laws around protection of children and youth in motor vehicles.
What is the biggest change in the new policy? The most significant change is the new recommendation that children under 2 years should ride rear-facing as long as they have not outgrown the weight or height limit for their seat. The previous recommendation advised that it is safest to ride rear-facing to the limits of the seat, but also cited age 12 months and 20 pounds as a minimum. The change reflects recent evidence about the benefits of rear-facing, and also is intended to simplify the message for parents. Additionally, the change is reflected in an algorithm that is intended to provide decision support for pediatricians, both on paper and as part of electronic tools, that will help pediatricians give more accurate, consistent advice to families.
Does the rear-facing recommendation apply to every child? The recommendation to ride rear-facing until age 2 is meant to apply to the vast majority of children, but there are some situations in which a child should turn forward-facing earlier or later. For example, children who are small for age, particularly those who were born preterm, or who have special health care needs might benefit from riding rear-facing for more than 2 years. Other children might reach the weight or height limit before age 2, in which case they should use a forward-facing seat with a harness. The “age 2” recommendation is not a deadline, but rather a guideline to help parents make a decision about when to make the transition.
Why is rear-facing safer than forward-facing? A 2007 study1 showed that children under 2 years old are 75% less likely to die or be severely injured in a crash if they are riding rear-facing. For children in the second year of life, it found that the risk of death or serious injury was 5 times lower when riding rear-facing. When a child rides rear-facing, the head, neck, and spine are all supported by the hard shell of the car safety seat and all move together, with little relative movement between body parts. When children ride forward-facing, their bodies are restrained by the harness straps, but their heads – which for toddlers are disproportionately large and heavy – are thrown forward, possibly resulting in spine and head injuries.
Won’t children be uncomfortable riding rear-facing for so long? Are they at risk for foot or leg injuries if their legs touch the vehicle seat? This is a very common concern, but one that is not supported by any evidence. There are no known detrimental effects of riding rear-facing longer than a year, but the benefits of doing so have been observed for many years in Sweden and more recently in the United States. Children have many ways of making themselves comfortable when facing the rear and can ride safely that way as long as they have not reached the weight or height limit for rear-facing in their seat. For many kids, this could be well past 24 months.
What are the rear-facing limits? These vary according to the particular seat; for infant seats, the limits are generally between 22 and 35 pounds. Convertible seats are larger and have higher limits, generally at least 35 pounds and some up to 40 or 45 pounds. Height limits vary also. The limits for each particular seat are listed on a label on the side of the seat and in the instruction manual. Convertible seats will also give limits for forward-facing use, so parents should be sure they are observing the right limits for how their child is riding.
How should children ride after they outgrow the limits for rear-facing? Children should ride in a forward-facing seat with a 5-point harness for as long as possible, until they reach the height or weight limit for forward facing. After that, they should ride in a belt-positioning booster seat until the seat belt fits correctly.
Why are booster seats important? Because vehicle seat belts were designed for adults. The lap and shoulder portions of the seat belt generally will not fit young children properly. If the shoulder belt lies close to the neck, it will be uncomfortable for the child, who might then put the shoulder belt under his arm or behind his back where it cannot provide upper-body protection in a crash. If the lap belt sits high over the child’s abdomen, the child could sustain severe injuries to abdominal organs. The booster seat keeps the lap and shoulder belts over strong bones where they were designed to be, instead of the soft abdomen or neck.
How do you know when the seat belt fits correctly? The seat belt fits correctly when the shoulder belt lies across the middle of the chest and shoulder, not near the neck or face; the lap belt is low and snug on the hips and upper thighs, not across the belly; and the child can sit all the way back against the vehicle seat with knees bent without slouching, and can stay that way comfortably for the whole trip. This is usually around 4 feet 9 inches in height, and between 8 and 12 years of age. Although most state booster seat laws only cover children up to age 6 or 8, the vast majority of kids do not yet fit correctly in seat belts at those ages. Parents should not assume that their child is safe to ride in the seat belt alone because he has reached the age required by their state law, but should keep their child in the booster seat until the seat belt fits correctly without it.
Where in the vehicle should children ride? Children should ride in the rear seat until they reach age 13. Data show that children riding in the front seat are at 40% to 70% increased risk of injury. Riding in the back seat reduces the risk of injury in both frontal and side-impact crashes, and also reduces the severity of injury. If possible, it may be best for children to ride in the middle of the back seat; however, if it is not possible to install a car safety seat tightly or no lap and shoulder belt is available in the middle, then either side of the back seat is a good choice.
Is it safe for children younger than 2 to ride on a parent’s lap on an airplane? Although the Federal Aviation Administration permits children under age 2 to ride on an adult’s lap, they are best protected by riding in an age- and size-appropriate car seat. If parents do not wish to purchase a separate seat for their young child, they may be able to use an empty seat at no charge if one is available. Parents who do purchase a separate seat for their child can use a car safety seat onboard as long as it bears a label stating that it is approved for use on aircraft. In any case, parents should ensure that an appropriate car safety seat is available for their child’s use when they reach their destination.
Information for Child Passenger Safety Technicians and Advocates
Why is policy development such a long process? The policy development process is comprised of numerous steps, starting with obtaining approval from the AAP Board of Directors to develop the policy. Once approval is given, the authoring group (in this case, the Committee on Injury, Violence, and Poison Prevention) embarks upon analyzing new information, writing, and revising. For this policy, the committee also collaborated with the Partnership for Policy Implementation to ensure that the language was clear, specific, and suitable for integration with electronic health record tools. Next, the policy in progress is circulated to other AAP groups for internal peer review, followed by a period of addressing the reviewers’ comments with further revisions. This process is intended to identify and resolve any potential medico-legal problems or challenges related to feasibility of integration in pediatric practices. Finally, policies must be reviewed and approved by the Board of Directors; this process may involve multiple revisions as well. All of the internal processes are aimed at producing a policy that is scientifically sound and sensitive to the needs and situations of its audiences.
How can I get connected with pediatricians in my community? The new policy specifically advises that pediatricians familiarize themselves with resources in their communities, ie, Child Passenger Safety Technicians, who can support them in providing accurate information and handling more complex situations related to the safe transportation of children with special needs or other considerations. You can help by reaching out to the pediatricians in your community. If you are unsure about how to get started establishing these relationships, start with the AAP Chapter in your state; you can find contact information for the chapter’s executive director on the AAP Web site.
Additionally, the AAP plans to undertake a Child Passenger Safety Training Project, which would train pediatricians and the staff in their offices on best practice recommendations. This project will involve participation from Child Passenger Safety Technicians who are interested in taking an active role in providing education and resources to pediatricians. If you are interested in participating in this project, please contact Bonnie Kozial.
1. Henary B, Sherwood C, Crandall J, et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007;13(6): 398 – 402