Friday, 31 August 2018

Keep Children in Rear-Facing Car Seats Longer

Image from Consumer Reports article cited below
As we head into the new school year and the holiday weekend, it is a good time to remind parents and guardians to double-check their car seat usage.

The American Academy of Pediatrics (AAP) has issued new guidelines suggesting that parents keep their young children in rear-facing car seats until they reach the height or weight limits of that seat. 

In other words, don't be so eager to get those children front-facing because children really are safer rear-facing. 

In the past, AAP recommendations were age-based. Generally they recommended that children become front-facing at age two. But there is such a wide variation of size in children, even at the same age, that going only by age doesn't make sense. Also, research shows that rear-facing remains the safest position even for children older than two. Instead, parents should consult the height and weight limits of the car seat they use and use those to guide when to switch to front-facing.

Why Rear-Facing?

It's important to keep children rear-facing as long as possible because it protects the child's head and neck more completely. If a young child is front-facing and an accident occurs, the child's body is restrained but the head is thrown forward, placing tremendous stress on the neck and spine at a time when they are not very strong or developed. If the child is rear-facing in the same scenario, most of the force pushes the child's head and back into the support of the car seat behind them, lessening the stress on the back and limiting extension of the neck.

Research clearly shows that children are safer in rear-facing car seat positions whether the impact is from a head-on collision, a side-impact collision, or a rear-impact collision. This really is a no-brainer.

From the Consumer Reports article on car seat safety:
“Parents and caregivers should never be in a rush to move kids along to the next seat type or orientation,” says Emily Thomas, Ph.D., auto safety engineer at Consumer Reports’ Auto Test Center. “Each move to the next step can actually be a step down in terms of a child’s overall safety. In this case, making the transition to forward-facing too early exposes your child to head and spine injuries during a crash.”
General Car Seat Guidelines

Most parents do a pretty good job these days of using infant car seats correctly when babies are young. However, there is a distinct drop-off of proper use as the child gets older.

Car seat safety doesn't end when the child becomes a toddler or goes to preschool. Research shows that during routine car seat inspections, about one-third of children over 4 years of age were "suboptimally restrained." There's a lot of room for improvement here.

Consumer Reports suggests:
Parents can expect to need a minimum of three seats to best protect their children through the car-seat years: a rear-facing infant seat, a convertible seat (used rear-facing first, then transitioned to forward-facing when appropriate) and a booster seat.
Here are some suggestions for safer car seat use:
  • Start with a rear-facing infant seat or convertible car seat. Always place it in the rear seat. The middle of the back seat is the safest spot in the car for a child
  • Switch from a rear-facing infant seat to a rear-facing convertible seat "no later than your child's first birthday" This is because most babies outgrow their infant seat due to height, not weight, so be sure you pay attention to the height limits as well as weight limits
  • Get the best convertible car seat you can afford, one that goes up to the highest height/weight limits you can find. Children really are safer rear-facing when they are young so find the car seat that will let you keep them rear-facing the longest
  • Children should remain rear-facing until they have reached the height or weight limit for rear-facing children in that seat. At that point, switch to forward-facing in the convertible seat
  • Stay in the forward-facing convertible seat until the height or weight limit is exceeded for the forward-facing position. Only then should you switch to a booster seat
  • Use a booster seat until the child outgrows the height or weight limits of that seat and a lap/shoulder belt fits them properly. Most resources advise that children should be at least 4'9" tall and weigh at least 80 lbs. before they transition out of the booster seat. In some areas, 20% of child injuries under age 8 in car accidents resulted from using adult restraints instead of booster seats
  • Keep children in the back seat until the teenage years (at least 13; in some states it is 14). Air bags in the front are rated for adults and can seriously injure or kill children. Older children may look fairly grown but their skeletal systems are still more vulnerable to force injuries. Restrained children in the front seat are about 40% more likely to sustain an injury than restrained children in the rear seat
There are so many car seats brands and types; each has its own height/weight guidelines. When in doubt, follow the guidelines that came with your car seat.

Always keep the car seat's guidelines with the seat so they are easily found for reference. Tape them to the back or side of the seat. Some experts also recommend writing or attaching an ID tag to the car seat with the child's name, parent names, and pediatrician's name/number. That way if there is a significant accident and a relative is unable to give information or medical contacts, first responders have a lead on who the child is, their medical professional, and a way to find medical history. If your child has special needs, this is particularly important.

Remember that there are many car seat safety inspection clinics available in the community. Please use them. You can be very well-educated and still make mistakes that could be deadly.

Many hospitals host car seat clinics regularly, and many fire departments and police departments sponsor them as well. Many parents go to these inspections when their kids are babies, but do not attend them once the child reaches pre-school or school age, thinking that they now know what to do. Yet frequent errors are found in children between ages four to twelve, and faulty restraint is a major cause of trauma and mortality for children of that age. Don't assume you have it all down; rules change at times and it's easy to overlook a recalled seat or a change in guidelines.

Dealing with Pressure About Restraints

One reason parents don't restrain their children optimally is due to a misunderstanding of the current guidelines. Guidelines do change over time as a result of research, but they represent the best current science on car seat safety that we have. As the research evolves, so do the guidelines.

Unfortunately, many family members and community members aren't familiar with the latest research or minimize its importance. Many parents give in to pressure from family members or peers about car seat rules or simply get lax about them as children grow older.

I know that car seat safety was a continuing source of discord in our family as we raised our children. My husband and I are in agreement on most parenting issues, but not always on safety issues. He and his family felt that many car seat safety guidelines were excessive and unnecessary.

Front-facing vs. rear-facing was one of our biggest ongoing arguments. My husband and his family felt that I was being way too cautious by keeping my children rear-facing, especially once in a convertible seat. They wanted that child front-facing sooner than later. This was probably one of the most contentious parenting battles we had.

It certainly was very tempting to turn the seat forward so I could see the child better when I was driving. I hated not being able to see what was going on with my infant when it was just the baby and me in the car. Also, once they were a little older, the children themselves wanted to be forward-facing so they could feel like Big Kids. It became like a rite of passage emotionally, both to the kids and to other family members. These are understandable reasons why parents ignore the guidelines ─ but the safety of the child should be the top priority. Rear-facing is safer.

The fight over car seat safety didn't end there. My husband and his family also strongly pressured me to switch my children to a booster seat long before they outgrew the height/weight guidelines on the convertible seat. They felt I was being too much of a worrywart and the current safety recommendations were excessive. They also felt the children would be more comfortable in a booster. Still, I didn't give in. I knew the children were safer in a 5-point restraint than using an adult seat belt on a booster.

Then of course, as the children got well into grade school, the family thought it was ridiculous to still have the kids in a booster. They pointed out how much more convenient it would be not to deal with boosters when carpooling or going on field trips. This argument resonated with me because not having boosters would certainly be easier, and I saw many of my children's peers starting to go without boosters. But again, boosters were safer and that's what really mattered. I gritted my teeth and held strong.

The battle continued as the children became pre-teens. They were no longer in boosters, but now they wanted to ride in the front seat instead of the back. My husband was particularly susceptible to this argument. We had to have this discussion multiple times until the law mandated that pre-teens had to be in the back. Then he had no choice but to follow the rules or risk a ticket.

He and his family always had good intentions and they were loving, supportive relatives, but they had a real blind spot about car seat safety. They simply refused to believe the guidelines. However, this was one thing I would not compromise on. 

The safety of my children was always the MOST important thing and I knew the research. So I put my foot down on this battle and would not budge, but let me tell you it wasn't easy sometimes. In the end, it was a battle worth sustaining.

Before you head out to school or on family trips, take a moment now to review the guidelines, review the height/weight limits on your current car seats, write in your children's IDs, and make sure they are properly restrained. Better safe than sorry.



Resources


J Trauma Acute Care Surg. 2015 Sep;79(3 Suppl 1):S48-54. doi: 10.1097/TA.0000000000000674. Car seat inspection among children older than 3 years: Using data to drive practice in child passenger safety. Kroeker AM, Teddy AJ, Macy ML. PMID: 26308122
BACKGROUND: Motor vehicle crashes are the leading cause of unintentional death and disability among children 4 years to 12 years of age in the United States. Despite the high risk of injury from motor vehicle crashes in this age group, parental awareness and child passenger safety programs in particular may lack focus on this age group. METHODS: This is a retrospective cross-sectional analysis of child passenger safety seat checklist forms from two Safe Kids coalitions in Michigan (2013) to identify restraint type upon arrival to car seat inspections... Just 10.8% of the total seats inspected were booster seats. Child safety seats for infant and young children were more commonly inspected (rear-facing carrier [40.3%], rear-facing convertible [10.2%], and forward-facing [19.3%] car seats). Few children at inspections used a seat belt only (5.4%) or had no restraint (13.8%). Children 4 years and older were found to be in a suboptimal restraint at least 30% of the time. CONCLUSION: Low proportions of parents use car seat inspections for children in the booster seat age group. The proportion of children departing the inspection in a more protective restraint increased with increasing age. This highlights an area of weakness in child passenger safety programs and signals an opportunity to strengthen efforts on The Booster Age Child.
J Pediatr. 2017 Aug;187:295-302.e3. doi: 10.1016/j.jpeds.2017.04.044. Epub 2017 May 25. Factors Associated with Pediatric Mortality from Motor Vehicle Crashes in the United States: A State-Based Analysis. Wolf LL, Chowdhury R, Tweed J, Vinson L, Losina E, Haider AH, Qureshi FG. PMID: 28552450
...Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers <15 years of age involved in fatal MVCs, defined as crashes on US public roads with ≥1 death (adult or pediatric) within 30 days. We assessed passenger, driver, vehicle, crash, and state policy characteristics as factors potentially associated with MVC-related pediatric mortality. Our outcomes were age-adjusted, MVC-related mortality rate per 100 000 children and percentage of children who died of those in fatal MVCs. Unit of analysis was US state... RESULTS: Of 18 116 children in fatal MVCs, 15.9% died. The age-adjusted, MVC-related mortality rate per 100 000 children varied from 0.25 in Massachusetts to 3.23 in Mississippi (mean national rate of 0.94). Predictors of greater age-adjusted, MVC-related mortality rate per 100 000 children included greater percentage of children who were unrestrained or inappropriately restrained (P < .001) and greater percentage of crashes on rural roads (P = .016)... For 10% absolute improvement in appropriate child restraint use nationally, our risk-adjusted model predicted >1100 pediatric deaths averted over 5 years....



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