How AAP car seat guidelines have been updated

Benjamin Hoffman, MD, FAAP, CPST-I

The American Academy of Pediatrics (AAP) has changed the age recommendation regarding rear-facing car seats, advising that children remain rear-facing for as long as possible.

The change, outlined in a new policy statement from the AAP’s Council on Injury, Violence, and Poison Prevention,¹ was spurred by questions about the 2007 study that was used to develop the last recommendation in 2011 that children remain rear-facing until age 2 years.

Benjamin Hoffman, MD, FAAP, CPST-I, professor of Pediatrics at Oregon Health and Science University (OHSU), medical director of the Tom Sargent Safety Center at OHSU Doernbecher Children’s Hospital, and director of the Oregon Center for Children and Youth with Special Health Needs (OCCYSHN), Portland, Oregon, helped develop the new recommendation for the AAP and says that data used in the 2007 study was called into question because of the statistical analysis used. A reexamination of the methodology revealed inconsistencies, Hoffman says, and the 2007 study was retracted.

When the original research team performed a new analysis of the original data from 1998-2003, and also looked at subsequent years through 2015, they concluded that at all ages examined, rear-facing car seat use was associated with a decreased risk for injury; the number overall were insufficient to confidently recommend a specific age to transition. Consequently, the policy, specifically recommending age 2 years, needed to be changed.

“We knew that if our policy said rear-facing until age 2 and we could not back that up specifically, and that it would be used for the purposes of changing laws, we needed to change our guidance to reflect the best available evidence,” Hoffman says.

For the purpose of civic policy and state law, it is necessary to address straightforward parameters, such as age, weight, and height. Hoffman admits that this newest change means that it is hard to recommend specific parameters, and this can lead to some confusion. However, Hoffman says the evidence is clear that rear-facing is best as long as feasible, adding virtually every convertible car seat can accommodate children rear-facing either direction up to 40 pounds, and that means that virtually every child can stay rear-facing in virtually every seat until at least their second birthday. Although many parents may be concerned about their child’s comfort, the fact is, Hoffman says, it is more a concern for parents than a real problem for children, and that safety should always be the primary concern.

“Parents always worry about the legs. Kids are super flexible and super adaptable, and they can always find a comfortable position,” Hoffman says. “Arms and legs are rarely injured in the rear-facing position, and the head, neck, and spinal cord are protected better rear-facing. We can fix arms and legs, but we can’t fix heads, necks, and spinal cords.”

Specifically, the new recommendations state that children should remain rear-facing for as long as possible based on the limits of their car seat. Based on normal growth patterns and seats that allow a maximum weight of 40 pounds rear-facing, this would include almost all children aged younger than 2 years, and even the majority up to 4 years of age. Furthermore, the recommendations state that children who have been turned to forward-facing positions remain in car seats with harnesses as long possible, up to the seat’s weight and length limits, noting that most seats can accommodate children up to more than 50 pounds.

The guidance also advises that children who outgrow car seats be placed in a belt-positioning booster seat until they can use a vehicle’s lap and shoulder belt in the correct position. Finally, the guidelines recommend that all children aged younger than 13 years remain restrained in the rear seats of vehicles for the best protection.

Hoffman says the updated guidance should encourage pediatricians to talk to parents about delaying car seat transitions as long as possible because the next step always means less protection and an increased risk for injury.

“Nobody’s saying that all kids have to stay rear-facing until age 4, but many could,” Hoffman says. “It’s not about creating a nanny state, but car crashes kill more kids than any other cause. The longer parents and caregivers can delay transitions, the fewer children will be injured and killed.”

References:

1. Durbin DR, Hoffman BD; Council on Injury, Violence, and Poison Prevention. Policy Statement: Child passenger safety. 2018;e20182460. Epub ahead of print. Accessed October 23, 2018.