Child safety seats: Why rear-facing is so important

“Rear facing or not rear facing, that is the question” is an obvious referral to Hamlet. However, the referral goes beyond merely words. In this scene, Hamlet is contemplating suicide and bemoaning the unfairness of life, much like a 20-month-old might (and if you have ever had one, you know how true this statement is) about sitting backward in a car seat.

But even morose Hamlet realizes that the alternative is worse, with “the undiscovered country, from whose bourn no traveler returns, puzzles the will, and makes us rather bear those ills.” Obviously, William Shakespeare did not realize how applicable his words would be to the most recent AAP recommendations on car seat use.

In 2018, the AAP released an updated statement and accompanying technical report on child passenger safety. Here are the new 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 the seat. Most convertible seats have limits that will allow children to ride rear facing until age 2 or older.
  • Once 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 the 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 often is when they have reached at least 4 feet 9 inches and are 8 to 12 years old. South Carolina law requires children to sit in a booster seat until a minimum of age 8.
  • When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts properly (i.e., with the shoulder belt over their torso rather than behind them) for optimal protection.
  • All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

As a pediatric emergency medicine physician, I have both the fortunate and unfortunate opportunity to care for children involved in horrific accidents. The accidents we see in our Children’s Emergency Center could not highlight the need for these recommendations more strenuously.

Over the past year, we have had several motor vehicle collisions involving significant morbidity and mortality for patients. The most injured children were unrestrained and ejected/displaced passengers. In nearly every one of these traumatic events, the children properly restrained in a car seat/booster were discharged home with abrasions and bruises only. Proper use of a car safety seat or booster decreases the risk of death or serious injury by over 70 percent; this finding is absolutely supported by our experience.

These recommendations are not made lightly and are conservative for a reason. The initial studies that recommended a forward-facing seat at age 2 did not have a large enough sample size to have statistical significance. As a result, there is not enough evidence to advocate for a hard age for when this transition should occur; however, it is clear that a rear-facing seat provides a shell that protects the most vulnerable parts of a child’s body.

A forward-facing seat restrains the child’s body, but allows greater mobility of the head, which is disproportionately large and heavy. Delaying the transition to a forward-facing seat will protect the child. Note, though, that South Carolina law has not had time to adjust to the new recommendations. Therefore, the hard age of 2 years rule remains in effect, unless a younger child has outgrown their rear-facing seat.

Children are our future. I hope you will read these recommendations in their entirety and follow them with your own children. Even Hamlet recognized that bearing those ills was too great a price to pay.

Jeremiah Smith, MD, is a physician in Prisma Health Children’s Hospital–Upstate’s Children’s Emergency Center

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