Updated 12/19 (updated link and words in italics are updated language)

A few years ago, the US Department of Transportation looked at crash data and found a clear pattern.  Babies and toddlers facing backwards when the car crashed were far more likely to live than those facing forward.

The word was issued, and from that moment on all were advised to seat all babies and toddlers up to age 2 backwards, in the back seat, whenever in a car, period.

Now the American Academy of Pediatrics has updated their recommendations, and they make clear backwards is better at a much longer stretch of ages, up to age 8.  https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Updates-Recommendations-on-Car-Seats-for-Children.aspx

I would like to start this post by thanking a family in the practice who had heard of these changes in the news, they made me aware, and I am grateful.  Many families wonder, do we like families researching the Internet, the answer is for sure a big YES!  Your input is critical to us being as good as we can be in helping you.

The official AAP policy recommendations will be published in the November 2018 issue of the AAP journal, Pediatrics.

http://pediatrics.aappublications.org/content/142/5/e20182460

The New and Current Recommendations

1. The best position in a car for all children is rear facing, but one can only be placed rear facing if the child’s safety seat fits them in that direction.  Nearly all rear facing safety seats can only accommodate a child up to 35-40 pounds in the US.   A second reason to move from rear to forward facing is if the top of your child’s head is taller than the back of the safety seat.  This often happens by age 2 or so.
2. Once a child outgrows a rear facing car safety seat, they must face forward, and remain in this safety seat until they outgrow it, and then go to a booster seat until they are 4’9″.
3. For children ages 8 years old and under, they will not be able to sit facing rear if their car seat device cannot hold them because they are bigger than the seat can hold safely.

The key here for all children is their weight.  And it’s the brand and model of your car seat.

It’s a Car Seat, not an Infant Seat- Making Sense of the New Recommendations

Adults buy cars, so cars are built for people who are taller than 4’9″.  This means that people under 4’9″, essentially all children, don’t fit the car’s seat belt and shoulder belt.

So, companies have been good enough to create adapters to help those under 4’9″ to fit in the car with seat belts and shoulder belts that actually fit to work.

These adapters are plastic shells built to hold a child.  The size of the shell, the adapter, defines what size child they will work for.

It really has nothing to do with being a baby, some sort of adapter is necessary for all children under 4’9″

Now, it turns out the companies making these adapters tend to make them to hold people up to 40 pounds.  No one is 4’9″ when only reaching 40 pounds.  Hence the emergence and use of booster seats.  A 41 pound child whose adapter, car seat, can only hold a child up to 40 pounds, must leave the world of the complete solution adapter and to the world of booster seat, which is a partial adapter.

So, the new recommendations turn into the following new practice.

• If your car seat holds a person up to 40 pounds, then your child should be in that seat whenever in a car, until they weigh over 40 pounds, and if they are under 9 years old during this time, face backwards for that entire period.
• If your car seat holds a person up to 65 pounds, then your child should be in that seat whenever in a car, until they weigh over 65 pounds, and if they are under 9 years old during this time, face backwards for that entire period, unless, again, their head is taller than the back of their car safety seat in which case they do switch to facing forward.
• If your child is 9 years old or older, they should face forward, and remain in a booster seat until taller (weight no longer matters) than 4’9″.

For more details on the broader set of AAP recommendations we present this overview of AAP recommendations:

• Infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for 2 years or more.
• Once they are facing forward, children should use a forward-facing car safety seat with a harness for as long as possible, until they reach the height and weight limits for their seats. Many seats can accommodate children up to 65 pounds or more.
• When children exceed these limits, they should use a belt-positioning booster seat until the vehicle’s lap and shoulder seat belt fits properly. This is often when they have reached at least 4 feet 9 inches in height and are 8 to 12 years old.
• When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection.
• All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

Most important is to use a car seat for every trip,

Using the right car safety seat or booster seat lowers the risk of death or serious injury by more than 70 percent.

BOTTOM LINES

1. We often talk about dangers to the lives of our children, and tobacco, obesity, other choices we make figure prominently in those discussions, but the actual #1 cause of death from ages 1-50 is injury, and one of the top injuries that lead to loss of life is car accidents.  
2. To an amazing degree, if we look at activities we do in our lives, driving in a car is usually the most dangerous activity anyone does in their life.
3. Positioning your child in your car in the right place, in the right direction, in the right apparatus is THE BEST way to save lives while driving.  As noted, doing it right drops the number of children who die in car accidents by 70 percent.
4. It is increasingly clear the best position to be in during a car accident is facing backwards if your head is resting on an apparatus.  The only apparatus that allows this position to work is the car seat.  
5. THEREFORE, WE NOW URGE ALL FAMILIES TO HAVE THEIR CHILD SIT IN THE REAR, FACING BACKWARDS, IN A CAR SEAT UNTIL THEY OUTGROW THEIR CAR SEAT, OR REACH AGE 9 YEARS OLD.
6. The car seat is not a baby seat or an infant seat, it is a device to adapt a child to sit safely in a car, which are all designed to fit adults, not children, for use of seat belt and shoulder belt.   There is NO AGE at which one seeks to have your child leave a car seat, these adapters adapt the young body to the adult car until they outgrow them, some at 40 pounds, some at 65 pounds, depending on the weight tolerance the manufacturer defines.
7. Once your child outgrows a car seat, the key number shifts from weight to height.  They go from car seat to booster seat, a weaker adapter than the car seat, but able to fit a seat belt and shoulder belt until your child’s height reaches 4’9″

Driving in cars is dangerous, and deaths from car accidents a major cause of death.  Making sure our children ride as safely as possible can put a 70% dent into this danger.  These new guidelines will change the way families ride in a car together.  But so did the invention of seat belts, and then car seats.  In each instance we all grumbled, many resisted, but in time, the clear improvements won the day, I am confident these recommendations will become part of the American routine of riding in our cars, too.

To your health,
Dr. Arthur Lavin