The impact of the revised policy should be minimal, as the only significant change
is the removal of a specific age, 2 years, as a criterion for when a child changes
from a rear- to a forward-facing car safety seat.
Guidance for families
Pediatricians should be prepared to provide advice at every health maintenance visit
to ensure that children are as safe as possible. The evidence-based recommendations
call for the following:
Children should ride in a rear-facing car safety seat as long as possible, up to the limits of their car safety seat. This will include
virtually all children under 2 years of age and most children up to age 4.
Once they have been turned around, children should remain in a forward-facing car safety seatup to that seat’s weight and length limits. Most seats can accommodate children up
to 60 pounds or more.
When they exceed these limits, child passengers should ride in a belt-positioning booster seat until they can use a seat belt that fits correctly.
Once they exceed the booster limits and are large enough to use the vehicle seat belt
alone, they should always use a lap and shoulder belt.
All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
The recommendation for rear-facing car seats has taken some twists and turns.
For the previous (2011) policy (http://bit.ly/2B788GJ) and technical report (http://bit.ly/2OBXiOT), the AAP Committee on Injury, Violence and Poison Prevention reviewed the four stages
of child passenger safety: rear-facing, forward-facing, booster seats and seat belts.
For each stage, the best available evidence was to delay transitions as long as possible,
up to the manufacturer’s recommended limits for weight and length. The policy said
children should ride in rear-facing car safety seats until at least age 2 years.
The recommendation was based in part on a 2007 study that found decreased risks of
injury for children ages 1-2 years who were rear-facing in a crash compared to forward-facing
(Henary B, et al. Inj Prev. 2007;13:398-402). The findings were consistent with biometric research, crash simulation
data and experience in Europe, especially Sweden, where many children rode rear-facing
for much longer than U.S. children.
While the “rear-facing until 2” recommendation sparked much discussion when it was
published, the policy’s impact has been beneficial. Since 2011, car seat manufacturers
have developed innovative products that allow children to ride rear-facing until they
reach 40 or more pounds, ensuring that virtually all children can remain rear-facing
until at least their second birthday. Further, some states enacted laws requiring
In 2016, however, a car seat manufacturer was sued after a child between the ages
of 1-2 years was critically injured in a forward-facing seat. The manufacturer allowed
children younger than 2 to ride forward-facing, though it recommended rear-facing
up to the seat’s limits. For part of its defense, the manufacturer employed an independent
statistician to re-examine the data from the 2007 paper, along with data from subsequent
years. The findings called into question the original analysis, suggesting some methodological
Then, a contingent of the original research group performed a robust re-analysis and
found that while the trend was for rear-facing to be superior to forward-facing for
children under 2 years, the numbers were too low to reach statistical significance
As all evidence continues to show the relative superiority of rear-facing, the Academy
continues to recommend that all children ride in a rear-facing car safety seat as
long as possible, up to the manufacturer’s stated weight and length limits. Currently,
no manufacturer allows for any child under 12 months to ride forward-facing, and several
require all children under 2 years to ride rear-facing.
The policy statement includes a decision algorithm to help practitioners provide the
safest guidance to families. Decision points occur for children younger than 4 years,
4-8 years and older than 8 years.
In most families, milestones and transitions are viewed in a positive light. Child
passenger safety is one of the few areas where the next step is not “positive” and
where delaying transitions is best practice. It is incumbent upon child health providers
to help families and caregivers do everything they can to protect child passengers,
at every age and at every stage.
Dr. Hoffman, a lead author of the policy statement and technical report, is chair
of the AAP Council on Injury, Violence and Poison Prevention Executive Committee.