The American Academy of Pediatrics, citing a substantial increase in scientific evidence backing best practices for child passenger safety, is recommending changes in child car seat use that include keeping most infants and toddlers in rear-facing safety seats until they reach age 2 years, according to a new policy statement released March 21.
The new guidelines also recommend forward-facing car safety seats for most children until they outgrow the weight or height limits on those seats; belt-positioning booster seats for most children through age 8 years or well beyond; and lap-and-shoulder belts for all those children who have outgrown booster seats. In addition, the policy statement recommends that all children ride in the back seat of vehicles through age 12 years (Pediatrics 2011;127:788-93).
Although the AAP policy recommendations are not binding, states use them in crafting and revising child safety seat laws, said Dr. Benjamin Hoffman, an expert in child passenger safety and associate professor of pediatrics at the University of New Mexico, Albuquerque. Previous academy recommendations regarding the use of booster seats prompted many states to enact laws requiring booster seats for older children, which has improved safety dramatically, he said.
"The best way to get people to use child safety seats appropriately is to have state laws requiring their use," Dr. Hoffman said in an interview. "Our job is to help consumer organizations and states understand what the best practice is."
The new AAP guidelines represent big changes in the way car safety seat use has been viewed, said Dr. Hoffman, a new member of the AAP’s committee on injury, violence, and poison prevention, which crafted the recommendations. Now, there’s much more emphasis on the transitions between different types of seats – rear-facing seats to forward-facing seats, forward-facing seats to booster seats, and booster seats to seat belts.
"In these transitions, you lose protection every step of the way," he noted. "Therefore, you need to delay these transitions for as long as possible."
However, many parents and even older children themselves view the transitions as milestones, which encourages them to make the transition as quickly as they legally can, he said. "Parents are really viewing these transitions as graduations. There’s a perception that this graduation is a positive thing. It’s not."
Instead of making the switch to a lower level of protection as soon as they’re legally able, parents should keep their children in safety seats until they outgrow the weight and height limits, Dr. Hoffman said. For example, many rear-facing seats can handle children up to 35 pounds, and parents should use these seats in their rear-facing configuration until their children no longer can fit in them.
Likewise, parents should keep their children in forward-facing car seats until they have outgrown the weight or height limits on those seats, and should use a belt-positioning booster seat until the vehicle lap-and-shoulder belt fits properly, typically when children have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.
According to the technical report by committee member Dr. Dennis R. Durbin, professor of pediatrics and epidemiology at The Children’s Hospital of Philadelphia, research in Sweden shows that rear-facing child safety seats reduce the risk of significant injuries by 90% relative to unrestrained children. Many infants and children in Sweden remain in rear-facing seats until age 4 years, when they transition directly to booster seats, according to the report (Pediatrics 2011;127:e1050-66).
"There’s a 500% increased risk of injury" for toddlers between the ages of 1 and 2 years when seated in a forward-facing seat, compared with a rear-facing seat, Dr. Hoffman said.
Analysis of the data also indicates substantial benefits for children aged 2 years and older seated in forward-facing car seats, compared with just booster seats or seat belts, and for children seated in booster seats who have outgrown car seats but who have not yet reached 4 feet, 9 inches, according to the report.
Some forward-facing seats can accommodate children up to 65 or 80 pounds, and should be used until that weight limit, according to the report.
Pediatricians should counsel their patients on these new recommendations at every well-child visit, the guidelines say.
"Pediatricians don’t have to know how to install car seats, but they have to know what the best recommendations are," said Dr. Hoffman. "They should know what the resources are in their communities [for car seat installation help], and it would be even better for them to make contact with those resources" in order to facilitate assistance for patients who might need it.