Turn the Seat Around

First, I must confess. I fear that what I am about to write might appear hypocritical, or at minimum incongruent.

I did it. I was the one who turned my son's car seat around. Against my husband's wishes. After months of trying to persuade him, I just did it-- without shared decision-making, without permission, without blessing. I was in the parking area outside of my mother's house, and I simply unclipped the seat, flipped it around, and clipped it back in. It took my husband a week to notice.

My son was two-and-a-half at the time, and my arguments were definitely not evidence-based. My primary motivations were convenience and annoyance: I was frustrated by not being able to hear what he had to say when I was driving; I was forever trying to reach my right arm back in impossible positions to wipe his runny nose; I was traumatized by the one time he threw up and I had no idea until I got out of the car; I wanted to see his eyes in the rear view mirror.

My husband and I bickered about this transition for months. Each time we traversed the topic, he threw my own words at me, the very evidence-based information I had shared with him after a lecture I had attended on motor vehicle safety years before: "He is safer facing backwards. The longer the better". Gosh, why doesn't he remember so clearly all the other things I want him to remember? My husband still gets emotional when the topic of the car seat comes up-- he even threatened, as I was writing this entry, to turn him back around.

And he is right. No doubt about it.

Children are safer facing backwards. Adults are safer facing backwards. Shoot, if the driver could be facing backwards and still drive, the driver would be safer too. Here's why.

We have made great strides in motor vehicle safety since my family drove across country in 1982. I was five at the time; the dog and I were carefree and entirely seat belt-free in the backseat area of our VW Rabbit. The seat was even removed for our comfort! It was a play land of books-on-tape, baby dolls and art projects, and it turned out to be both a fun and uneventful trip. Nowadays, our children are strapped in five-point harnesses just to run to the grocery store. And, though annoying and restrictive, this is a good thing. Car safety has been a great public health success story.

I don't think you'll be terribly surprised to learn that pediatric motor vehicle accident deaths have been cut in half in the last thirty years. Yes, in half. Car seats work. (Can I hear "Woot woot" for car seats!?) And while we should definitely celebrate this amazing improvement, motor vehicle crashes are still the leading cause of death in children in the US (see here for the data).  In 2009, 1314 children ages 1-14 were killed in car crashes, and an estimated 179,000 were injured. I think you would agree that one child dying in a car crash is too many.

Until recently, it was recommended (in the US) that infants and toddlers be kept in rear facing car seats (RFCS) until at least age one year and a minimum weight of twenty pounds. Once children reached those milestones, parents were told (often by their doctors) that they could keep their children rear-facing but only if the car seat could accommodate them, based on height and weight. If not, they were advised to use a front facing car seat (FFCS). As most RFCS had weight-limits around 22 pounds, many  parents interpreted this counsel to mean not only that they could turn their child around, but in fact they should. And they did.

Even with the old recommendations, it was reported at the time that 30% of children were turned around before the age of one.

In March 2011, the American Academy of Pediatrics (AAP) together with the National Highway and Traffic and Safety Administration (NHTSA) updated their recommendations. They did so based on several US and European studies showing that children facing backwards (in RFCS) are simply safer than children in any other type of seat in any type of crash.

Much of the data already existed for decades--extracted from Volvo test data done in Sweden-- showing that RFCS are safer. In a Swedish study, looking at accidents involving 3670 children from 1987-2004, ages 0-15 years, testers found the most protection for RFCS (90%, compared to unrestrained child). Boosters for children ages 4-10 were found to be 77% effective (compared to unrestrained). Please do note that they are not comparing RFCS to FFCS. (Here are links to the studies, if you are interested: Jacobsson et al. 2007, Isaksson-Hellman et al. 1997).  As a result, in Sweden, it is standard practice for all children to be facing backward until age four and then transitioned immediately to a booster seat. It's tough to even find a FFCS!

The big US study that turned the tables was published in the Journal of Injury Prevention in 2007 (Henary et al. 2007) and found the following key findings:

• Children in FFCS  were more likely to be injured than children in RFCS in all crash types (rear, frontal, and side)
• In side-crashes, children in FFCS were  5.5 times more likely to be injured than children in RFCS
• In frontal-crashes, RFCS were marginally safer, 1.2 times safer than FFCS (but, interestingly, this was not noted to be statistically significant).
• Looking specifically at children between the ages of one and two (previously many were turned around), this age set was also 5.5 more likely to be injured in FFCS compared to RFCS
• The overall effectiveness of RFCS was 93%, compared to FFCS, which was 78%

A 2009 paper published in the British Medical Journal (BMJ) was titled "Advise use of rear facing child car seats for children under 4 years old". Similar to the US, standard in Great Britain has been to turn children around at 9 kilograms (19.8 lbs, which is 8 months of age for an average boy).

Why are RFCS better?
 Babies are shaped differently than adults. They are more head and less body (see image below). They also have weaker necks than we do and are not designed to withstand high impact crashes even at relatively slow speeds. RFCS have been shown to better support torso, neck, head, pelvis, and to distribute the  impact of a crash throughout the entire body rather than just at sites of belt contact. Because of their disproportionate head and weaker necks, providing targeted support changes outcomes. It keeps children safer.
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Thankfully, these days, most of the newer infant car seats actually have new weight limits (up to 40 pounds), making it more convenient to keep children rear-facing. However, I cannot even tell you how often parents look at me sheepishly, tell me they've already turned their child, and basically state they have no intention of turning them back around.

Personally, I start counseling my parents about the updated recommendation to keep their children facing backward at the 6-month well-child visit. I remind them that driving our kids around town is literally the riskiest thing we do to them. This is no joke.  I repeat the message at the 9-month and 1-year visits. Why be so redundant? Sometimes I feel like a nag, but I am trying to catch families before they make the switch-a-roo. Because it's virtually impossible to go back. And because, for reasons that are kind of unclear, people have a hard time with this issue.

When I counsel people to reconsider, parents often give me similar reasons to the ones I gave my husband. They want to see, hear, and physically access their child while driving. The child seems happier; they don't cry so much. They also more often than not shrug and say, "Well, he is just too big to have his feet crammed up there against the seat like that." My response? Does your child ever complain of achy knees or a stiff back? Doubt it. Most little ones have no idea that they are supposed to "feel uncomfortable" with their legs up against the seat. They are comfortable in almost any crazy, bizarre, and twisted position. I mean, do you ever watch them sleep? I am sorry, but this is a projection problem-- in other words, my adult self definitely would feel uncomfortable in that position for any length of car ride; therefore, my child must feel terribly cramped too.

http://babyology.com.au/wp-content/uploads/2011/04/Child-seats.jpg

In fact, my son (it's been not quite six months since he was turned around), still positions his two feet up on the front seats with his legs extended in exactly the same way he was positioned when he was facing backwards. With rare exceptions, as exemplified in Sweden, where it is standard practice to keep ALL children facing backwards until age 4, children  of all sizes do just fine crammed into that rear facing seat.

Please make an informed decision and at least consider the implications of turning your child around before the age of two. Remember, as my husband correctly says, "He is safer facing backwards. The longer, the better."

And for more information on which car seats to how to install them, check out this site.

http://farm2.static.flickr.com/1204/1024886238_c9321f8bf6.jpg

Additional References
http://injuryprevention.bmj.com/content/13/6/398.full (injury prevention)
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv19/05-0330-O.pdf (swedish study)
http://www.cdc.gov/features/passengersafety/


https://sites.google.com/a/umich.edu/cpsbestpraci/resources/rear-facing-child-restraints
http://community.nytimes.com/comments/www.nytimes.com/2011/03/22/health/policy/22carseat.html
http://www.carsafetyrules.com/swedes-save-more-lives-with-policy-of-keeping-one-year-olds-with-rear-facing-car-seats/0403/