We have a study about rear-facing in the USA. It’s a good paper. It was also a major factor in promoting policy to rear-face until age two as a minimum. One main conclusion: “Effectiveness estimates for Rear Facing Car Seats (93%) were found to be 15% higher than those for Forward Facing Car Seats (78%)“. Impressive.
The study has weaknesses, though. Small sample sizes for one. Including injury measures of ISS9 severity may be another*. No quantification in terms of child’s age by month is yet another, combined with the data being limited to 23 months of age. Looking for data to find the exact benefit to rear-facing for a 12-month old child? Forget it. Due to the complexity of child passenger safety issues, the authors suggest that the, “findings cannot be analyzed in a vacuum.” Yet, many of us do. We throw out a five times safer mantra flippantly from its results, without having read the study or knowing when that number might even apply. All too often, that mantra is phrased to imply that 5x more kids die or suffer permanent injuries because they were not kept rear-facing as long as possible, something totally unsupported by the study.
Among the other drawbacks to this study, the data is now well over 10 years old. It studied crashes from 1988-2003, meaning the vehicles and carseats involved in those crashes were mostly less safe models from the 1980s and 1990s. Another drawback was limited information on misuse. Also worth noting, it mostly discussed the risk of injuries* rather than being limited to fatalities or even critical/permanent injuries. Suppose you are an astute parent or advocate who has properly restrained your 24-month old child in the back of a newer minivan, according to the owner’s manual of a convertible carseat from our Recommended Carseats list. You actually read the instructions and discovered that it allows them to be either rear or forward-facing at their age, weight and height. You’d like to know the difference in risk of your child being killed or permanently injured. Sorry, that “5x safer” number doesn’t apply. Nope, not at all. We simply have no published and peer-reviewed research from recent years to provide useful statistics like this.
Maybe Sweden is the answer, they have the data, right? After all, they keep kids rear-facing until around 4-years old and report nearly no fatalities to children of that age. Unfortunately, the nearly complete lack of children who are forward-facing in a 5-point harness system in Sweden means they don’t have comparative statistics, either. Also, their environment is very different from North America, from the level of education about transporting children safely to the age and types of vehicles and carseats that are in use. Plus, their population as a whole does not travel nearly as many millions of miles on the roads as we do in the USA. So, it is essentially impossible to make valid comparisons of injury or fatality rates that can be attributed only to rear-facing.
The fact is: we simply don’t know exactly how much safer rear-facing is in terms of critical injuries and/or fatalities for a properly restrained child in newer vehicles and carseats. We also don’t know at what age that the advantage of rear-facing starts to decrease significantly for properly restrained children.
So, what do we know? We know rear-facing is fundamentally safer. That is true for occupants of any age if a suitable restraint system is available. It’s a simple matter of crash physics. Rear-facing seats keep the head and spine in alignment to prevent internal injury. More importantly, they greatly reduce the risk of serious head excursion injuries compared to a forward-facing seat, particularly in side impacts. One result is an often overlooked concept that rear-facing seats tend to be more tolerant of certain types of installation and harness misuse. But most importantly, we know what factors cause deaths to kids in crashes and how to reduce them so the overall risk to a child is very low.
3-Years Old: Properly Used Forward Facing Seats are Very Effective Too!
So, what kills kids in crashes? Being unrestrained. Having a driver who is drunk or texting. Being in the front seat. These factors are major preventable risks. Many crashes are simply unsurvivable, especially side impacts from large SUVs and pickup trucks that are very common in the USA but relatively rare in Sweden, Japan and many other countries. Having a newer vehicle, newer carseat and following the instruction manuals will also help reduce risks. Should I put my child in the middle seat or outboard seat? Should I rear-face or forward-face my 3-year old? Should I buy a $40 convertible or a $400 model? These decisions may well affect the safety of the child, but may not be very significant once you have mitigated the major preventable risks. At least until the next study that says otherwise is published!
Quiz time:
In 2011, the AAP recommended that kids face the rear of the vehicle until at least 2 years of age and as long as possible. After that, they recommended kids be kept in a forward-facing seat with a harness until they reach the maximum weight or height for that seat. Prior to that AAP policy update, the minimum recommendation for rear-facing was 1 year AND 20 pounds. The vast majority of parents turned their babies forward-facing at about 12-months old at the time. Many still do. Similarly, most parents stopped using a forward-facing harness around 4 years and 40 pounds.
So, how many times more 1-year old children do you think died in crashes in 2011 and earlier, compared to infants under a year old? 5x as many? 2x 10x?
Similarly, how many more 4-year-olds were dying on the roads compared to 3-year-olds?
I don’t know of any peer-reviewed research to prove anything one way or the other, but the raw statistics are both tragic and interesting. They aren’t corrected or adjusted in any way, so it is impossible to draw any compelling conclusions. The numbers and some discussion can be found on our forum at Car-Seat.Org.
*The study included injuries rated ISS 9 or higher. ISS does not give any weight to head injury. A rating of 9 or less is sometimes considered a minor or moderate injury. A score of 16 or more is usually considered major or serious. Scores of 9 are very common, scores above 16 are much less common. A score of 25 or higher may be classified as critical or severe, while 75 is considered unsurvivable.
Update, minor edits: 7/2017
Though I agree with some of the comments above, I have to state that from a factual point of view it will *always* be safer to RF as long as possible, and that even for an adult RF is still safer.
I therefore think that it’s important to make people aware of the *Benefits* of rear facing, because there are in fact no bad points to it.
Focusing on FF correct use is also very important, and I do agree that “shoving it down your throat” is not a good thing to do, I advocate very verbally and in writing for ERF, not because I think FF makes you a bad parent, but because too few parents actually make an informed choice on the matter.
I think it’s important to look at it also from an anatomical view and what happens to us as we grow. And our anatomy tells us that to rear face as long as possible, and pref to a minimum of four years old, is safer, decreases the chances of life threatening injury in a crash.
The human body’s anatomy doesn’t change depending on where in the world you live, be it Scandinavia, France, Canada or America, and neither does pure simple physics.
I strongly believe that if we created car seats that rear faced to..lets say 4 years old, and ONLY rear faced (shock horror) , concentrated on educating personell and parents in installing these seats correctly and proper use of the seat (i.e how tight should the harness be, where should the american chest clip be, no heavy coats etc), I truly believe that every country in the world would see a *drastic* drop of injuries and death in children. If you made rear facing the norm, took away all the choices, because there are *far too many* of the choices in the seats, too many choices makes up for too many mistakes and misuses, you would see a huge positive difference.
Stepping away from ERF I would like to know if there are any studies conducted stating it is in fact beneficial to harness a child from 4 and up, as this was mentioned in the post.
It is true that we in EU have absolutely no choice but to use an adult seat belt once the child hits 40lb, which can be all from 2,5-4 years old, and no I really don’t think it’s safe to put a child that’s 3 years old in a HBB with the adult seat belt because I don’t think the child can be booster trained properly, and anatomically speaking the pelvis is not wide enough. (But this is solved by buying a car seat that rf to 55lb, remember that when you speak of Europe)
But has there ever been done a study that shows that it is SAFER to put a child who is 4 years old, in a harness, then if the child is using the HBB with seat belt *correct*.
We must always underline the correct use on both parts.
I ask because our reason (Europe) for not harnessing as you do in the States, is the load on the neck as the child grows. So has there been any studies done that proves this is fine to do? Or are we again arguing about it being different countries, therefore we are not the same?
I, too, agree with the above sentiments. It almost feels like there is this contest to see how long we can keep kids RF… 4,5,6 years old, how long we can keep kids FF harnessed…7,8,9+. All this focus on the extremes makes it even more difficult to reach those that just need help meeting the minimums, affording a seat, installing and using it properly, etc. I feel like a lot of this superiority isn’t even evidence based, and when there is any evidence, it’s summarily dismissed if it doesn’t line up with what these ERF and EH ideals. Companies get bashed by advocates for not making bigger and bigger seats, when they’re focusing on ease of use, ease of install, and other features that are likely to make parents more likely to use a seat and use it correctly. If you have the means to keep your child RF, FF harnessed, etc. that long, more power to you. Those of us in the real world will be focusing on helping people access seats, use and install them properly, and focus on more moderate RF and FF goals which the general public may perceive as more achievable.
I totally agree with Nicole’s comments. I’ve been an advocate of “extended rear-facing” since the term was coined, oh-so-many-years-ago but I’m also troubled by the trend I see of shoving it down parents’ throats and insinuating that they are bad parents, or just implying that you are a better parent and love your child more because you choose to rear-face to the limits of your seat.
Imagine if we put all the passion for ERF into something more productive, something that really is killing kids in large numbers – think of the impact we could make! Techs and advocates – it’s time to put the laptops and cell phones down, roll up our sleeves and get to work in the places where our passion and knowledge can have a real, MEASURABLE impact. If you’re serious about reducing the instances of death and injury to children in motor vehicle crashes you have to be willing to get dirty in places that might be outside of your normal comfort zone.
Hi Nicole- Great points. Forward facing seats are also very effective at preventing injuries, according to the same study. And the study didn’t account for many types of misuse, with one exception being carseats installed the wrong direction (like a forward facing infant carrier). That’s pretty important, since the big risk of critical injury is head injury from striking a part of the vehicle interior. A loose installation, loose harness and failure to use a top-tether are all common misuses. Those types of misuse likely contribute to greater head excursion and related injuries moreso for a forward-facing carseat than a rear-facing one, due to the physics involved. A correctly installed and used modern forward-facing carseat will almost certainly provide even better protection than the overall rates seen in that older study.
I’m much more concerned with the fact that many children are traveling unrestrained or severely improperly restrained. Those are the kids whose parents need reached and helped, not the forward facing 3 year olds. It’s troubling that a subset of the CPS community has lost sight of that fact.
When I no longer see forward facing infant seats, children with just the chest clip buckled, and toddlers bouncing around the back seat, I’ll think about making properly restrained forward facing 3 year olds a priority.