Rear view until age 2
Strong evidence supports new AAP child passenger safety recommendations
- Copyright © 2011 by the American Academy of Pediatrics
Guidance to help protect children from one of the top causes of mortality has been streamlined in a new AAP policy statement and technical report, Child Passenger Safety. Included is a significant clarification to prior AAP policy: All children should be restrained in a rear-facing position in the back seat of the vehicle until they reach age 2 or the highest weight or height allowed by the car safety seat (CSS) manufacturer.
The policy statement and technical report are available online and will be published in the April issue of Pediatrics (Pediatrics 2011;127:788-793OpenUrl).
At the heart of the policy are several other best practice recommendations for keeping children safe while riding in passenger vehicles:
1) Children ages 2 and older or those who have outgrown the rear-facing weight or height limit should remain in a forward-facing CSS with a harness for as long as possible, up to the limits allowed by the seat manufacturer.
2) All children whose weight or height is above the forward-facing limit for their CSS should use a belt-positioning booster seat until the vehicle lap-and-shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches tall and are between 8 and 12 years of age.
3) When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap-and-shoulder seats belts for optimal protection.
4) All children under age 13 should be restrained in the rear seats of vehicles for optimal protection. An accompanying algorithm guides pediatricians in finding a seat that meets the needs of most patients from birth to adolescence, factoring in details such as whether the child is small for age or has special health care needs.
Also updated is information on use of seats on airplanes (see Parent Plus) and child passenger safety in pickup trucks.
Facing backward, but moving forward
Child passenger safety has evolved dramatically over the past decade, according to Dennis R. Durbin, M.D., M.S.C.E., FAAP, a member of the AAP Committee on Injury, Violence and Poison Prevention (COIVPP) and author of the technical report.
Revisions to both documents reflect significant support, including 2009 National Highway Traffic Safety Administration (NHTSA) data as well as longstanding data from Sweden that demonstrate dramatically reduced injury and death rates of children who remain rear facing until age 4.
In updating the recommendations, COIVPP was careful to take into consideration availability and cost of products, Dr. Durbin said.
Thirty of the 35 convertible safety seats on the market can accommodate children to 35 pounds rear facing, according to the newly revised AAP Car Seat Guide (see resource box below). That weight exceeds the 95th percentile for boys and girls at 24 months of age, according to Dr. Durbin.
“As a general rule, we like kids to stay for as long as possible in the best possible restraint for their size,” he said.
When faced with the new guidance, parents may question the comfort of the child’s legs and safety during an accident when facing rearward, said COIVPP member Benjamin Hoffman, M.D., FAAP. However, “rear facing, it’s incredibly rare to have an injury to a limb,” he added.
“Families, especially those with smaller children, are always looking for developmental milestones,” noted Dr. Hoffman. “A lot of families view turning a child forward as a positive thing, whereas all the research we have supports the concept of staying rear facing as long as possible.”
Bigger seats for bigger kids
Automobile crashes remain the leading cause of death for children ages 4 and older. Despite this fact, parents often are eager to move a child from a harnessed seat to a booster or a lap and shoulder belt.
As of March 1, Arizona, Florida and South Dakota did not have laws requiring booster seats. Twenty other states require boosters only for children ages 6 and under, according to the AAP State Government Affairs’ 2010 State Legislation Report.
Fortunately, state legislators and NHTSA look to the Academy as an authority on child passenger safety, said AAP District V Chair Marilyn Bull, M.D., FAAP, who helped develop the child passenger safety technician certification program. The technical report’s ample resources can serve pediatricians and advocates as they push for stronger legislation regarding child passenger restraints for upper age limits.
Know your local authorities
It is possible but not necessarily recommended that pediatricians obtain National Child Passenger Safety Technician Certification like Dr. Bull and Dr. Hoffman, or pursue research like Dr. Durbin, whose motivation to focus on child passenger safety was the first preventable death of an infant due to an air bag deployment during a minor crash. The patient was treated at Children’s Hospital of Pennsylvania, where Dr. Durbin is co-scientific director of the Center for Injury Research and Prevention.
“Pediatricians are viewed by their families as a very important source of information on this topic,” said Dr. Durbin. “The extent to which pediatricians can put these recommendations into practice will really change they way most families in the U.S. restrain their kids.”
He advises pediatricians to familiarize themselves with resources provided in the technical report and materials available from the Academy, and to refer parents to local child passenger safety technicians (see resource box below) for additional information. “It’s no different than calling in a consult for any unusual or complex medical problem they might face in their practice.”
Points to share with parents
How can pediatricians get their message across about child passenger safety during a 15-20 minute examination?
AAP District V Chair Marilyn Bull, M.D., FAAP, advises pediatricians to memorize a few salient points and deliver what she calls an “elevator speech.”
Children under age 2 are 75% safer rear facing than forward facing.
Children in the second year of life are five times less likely to die or be seriously injured in a crash if rear facing than forward facing.
Only approximately 1 in 1,000 children who are rear facing will suffer a lower extremity injury. That rate is much higher for forward facing children.
The back seat is the safest place for all children to ride.
Access the algorithm in the AAP policy statement at http://pediatrics.aappublications.org/cgi/content/abstract/peds.2011-0213v1.
Access the technical report at http://pediatrics.aappublications.org/cgi/content/abstract/peds.2011-0215v1.
2011 Car Safety Seats: A Guide for Families includes data on products, prices and height/weight limits: www.healthychildren.org/carseatlist (login or click visitor).
Car Safety Seats: A Guide for Families 2011 (HE50275-11), a 32-page brochure, and the single-page Car Safety Seat Checkup (HE0276) can be ordered at www.aap.org/bookstore.
The National Child Passenger Safety Certification program offers a searchable link to local technicians and inspection sites: http://cert.safekids.org/.
Technicians trained to fit safety seats for children with special health care needs can be found at the Riley Hospital for Children Automotive Safety Program Web site: www.preventinjury.org/SNTtrainedPpl.asp.