The nation's largest organization of pediatricians is telling its members and parents that children riding in cars should remain in rear-facing child safety seats until at least their second birthday and preferably even longer.
This reverses advice many pediatricians gave parents for years that children's car seats should be turned around shortly after their first birthday.
The new policy from the American Academy of Pediatrics, published Monday in the Pediatrics medical journal, is buoyed by research that shows children under 2 are 75 percent less likely to die or be severely injured in a crash if they are in a rear-facing child restraint.
Equally important, the academy now recommends that children remain in a seat with a five-point safety harness as long as possible and should only transition to a booster seat that relies on the car's adult seat belts when children exceed the height and weight limit for the five-point harness.
Five-point harnesses, which run across children's shoulders and hips and buckle between their legs, provide more protection than a car's seat belts because they distribute the crash forces evenly over the strong, bony parts of a child's body.
The pediatricians also recommend that children remain in booster seats until they are 4 feet 9 inches tall — a height most kids don't reach until they are between 8 and 12 years old. This guideline exceeds Illinois' child restraint law, which is among the toughest in the nation because it requires children under age 8 to use child safety seats or boosters.
Some of the recommendations will likely be met with scowls from elementary school children, who often want to stop using their booster seats as they get older, and parents. Parents often welcome moving their children into a forward-facing position because their legs are getting longer and it gives the parent a better view of the child in the back seat while driving.
The central point of the report is that at every transition — from a rear-facing harnessed seat to a forward-facing harnessed seat to a belt-positioning booster — children lose some protection. So the pediatricians recommend that kids remain in each stage for as long as their car seats allow.
Even when kids are tall enough to solely use adult seat belts, the academy's policy is that they should remain in the back seat until age 13.
"Every parent wants their kids to achieve things as fast as they can," said Dr. Ben Hoffman, a University of New Mexico associate professor of pediatrics who helped write the new policy. "That's fantastic for developmental milestones or for school. But for child passenger safety, that's the wrong attitude to have."
On Monday, the federal government is set to issue its updated child seat guidance that echoes the pediatricians' advice.
While child car-seat use has dramatically reduced deaths and injuries in the last decade, vehicle crashes remain the leading cause of death for children 4 and up. About 1,500 children under the age of 16 die in vehicle crashes each year in the U.S., the Pediatrics report said.
Dr. Dennis Durbin, a pediatric emergency room physician at the Children's Hospital of Philadelphia and the Pediatrics report's chief author, acknowledges that some parents and children may balk at aspects of the new policy. Durbin is a father who understands that older kids are expert negotiators.
"There are certain things I'm willing to negotiate — bedtime, teeth brushing, broccoli for dinner — but safety is nonnegotiable," he said. "If parents establish that early in life, they'll get less push back over time."
Durbin recommends that parents who have turned a child to face forward on her first birthday now reinstall that seat to face the rear of the car. Many parents believe larger toddlers will be uncomfortable in rear-facing seats or will hurt their legs in a crash, but Durbin said they are mistaken.
When researchers at Durbin's hospital looked at children between the ages of 1 and 4 hurt in wrecks, leg injuries were rare for those in rear-facing seats, while they are the second most common injury for those in forward-facing seats, he said. That's because the legs of a child in a forward-facing seat are thrown forward in most crashes and can hit the console or the back of the driver's or passenger's front seat.
In a rear-facing mode, the seats act like cocoons, cradling children's heads, torsos, arms and legs in an accident, and spread the crash forces over a larger area.
Responding to concerns about comfort, Durbin tells parents that it's easier for kids to sleep in rear-facing seats because they are reclined, whereas, forward-facing seats often force nappers to slump uncomfortably. It's the norm in other countries for children to remain rear-facing as they grow older. Kids in Sweden typically remain in rear-facing car seats until they're 4, Durbin said.
American parents should carefully read their child-restraint instructions to make sure their children remain within the height and weight limits. A toddler with a very long torso may outgrow a rear-facing seat before age 2, and a heavy preschooler may exceed the weight limit for some forward-facing seats with five-point harnesses.
But the good news for parents with big kids is that most child-restraint manufacturers now offer convertible seats that allow a child to remain rear-facing until they reach 40 pounds. For instance, Sunshine Kids Radian XTSL has a 45 pound rear-facing weight limit and allows larger children to remain in a five-point harness facing forward up to 80 pounds.
Several manufacturers offer hybrid seats that permit the tallest and heaviest children to remain in a five-point harness before converting to a booster. The Britax Frontier 85, for example, allows kids with long torsos — those whose shoulders are 20 inches from the seating surface — to remain in a five-point harness until they reach 85 pounds, and it accommodates taller kids and those weighing up to 120 pounds in its booster mode. The Recaro ProSport allows children up to 90 pounds to remain in a five-point harness before converting to a booster for kids up to 120 pounds.
As seats have evolved in recent years, federal testing requirements haven't kept pace with the market. Many seats say they offer side-impact protection although the federal government has no side-impact standards for child restraints.
For rear-facing seats, the National Highway Traffic Safety Administration requires manufacturers to perform frontal crash tests using a dummy the size of a typical 12-month-old that's outfitted with instruments measuring the likelihood of injury. The seats can't exceed certain injury limits.
But for older and bigger children, the rear-facing tests are not as rigorous. The government requires that a dummy the size of a typical 3-year-old be used, but it does not mandate injury measurements. The results must solely show that the seats didn't crack and the dummy wasn't ejected.
Dave Clement, Sunshine Kids' director of engineering, said his company outfits the 3-year-old dummy with the injury-predicting instruments during its rear-facing tests and makes sure those readings don't exceed limits. Clement said he wishes the federal government would require this.
"It's the smart thing to do from a liability perspective," Clement said.
An about-face on children's car seats
Doctors say children should use rear-facing restraints until age 2
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