Evidence-based justification for extended rear-facing
Updated January 2022
It’s all the rage among parents nowadays: extended rear-facing. If you’re turning your child to face forward before they’ve reached the limits of their carseat, then you’re old-schooling it and increasing your child’s risk of injury in a crash. Many pediatricians still hold onto the now ancient recommendation of turning kids forward-facing at age 1 and 20 lbs., even though their own professional organization, the American Academy of Pediatrics, hasn’t recommended that since before 2002. You were probably in grade school then.
Why is it so critical for kids to stay rear-facing?
When you use the carseat right, it protects them and you from potentially being forever changed if you get into a crash.
Simple Physics Lesson
A carseat will always move toward the point of impact (Newton’s 1st Law). In a frontal collision—at 53.5%, statistically the most common type of severe/fatal crash—the entire back of a rear-facing carseat will protect the head, neck, and spine of a child as it rotates down toward the front of the vehicle. Even in a side impact, which is a more serious type of crash due to its proximity to passengers, there is usually an element of frontal movement, such as a vehicle moving forward through an intersection, as it’s hit from the side. So a rear-facing carseat will rotate down and forward, then toward the side where the impact occurs.
Click each graphic to see the motion:
Compare this to a forward-facing child in a harnessed carseat. In a frontal crash, the carseat still rotates down and forward toward the front of the vehicle, and the child will be flung forward into the harness and forward of the carseat shell. In a side impact, again the carseat rotates down and forward toward the front of the vehicle; the child comes forward into the harness and out of the carseat shell and there is rotation toward the vehicle door where the impact occurs. Because the harness is holding only the shoulders and hips, the head, arms, and legs are flung violently forward. If the harness is loose, which is one of the most common mistakes a caregiver makes, there’s a high likelihood of the child hitting the vehicle seat in front or the side pillar.
Anatomy 101
The folklore is that a child’s neck muscles aren’t developed enough to keep a baby’s neck safe in a car crash, which is why they have to face the rear of the vehicle. I suppose that’s true in a way: it does take babies time to develop their musculature so they can hold their heads up to keep their airways open. But the muscles don’t protect the fragile spinal cord, which is the bundle of nerve fibers that forms the central nervous system and is connected to the brainstem. No amount of baby push-ups will strengthen your child’s muscles to the point of protecting his spinal cord.
The bones of the spinal column are what actually protect the spinal cord and in infants and young children; they aren’t completely fused together for years. One of the most important cervical bones, the Atlas (C1), is what attaches the head to the spinal column. Drawings show where it ossifies, or fuses, at varying times: the anterior arch fuses around age 7, while the posterior neural arches fuse around age 3. Before it fuses, the Atlas and Axis (C2), the 2nd vertebra that the Atlas nestles into, are made of bone and cartilage, which is very pliable. These two vertebrae are held in place by ligaments, which are very elastic (lax) to allow the child to grow.
Studies of infant cadavers have shown that vertebral columns can stretch up to 2” but that the spinal cord is damaged after only ¼”. Given that a baby’s head accounts for ¼ of its total body size versus 1/7 an adult’s size, plus the immaturity of its vertebrae and laxity of the ligaments holding those vertebrae together, rear-facing seems the obvious choice.
The child’s large head shifts the fulcrum of movement—where the head swings forward—higher, elongating the spinal column and potentially causing catastrophic damage to the spinal cord. Before age 8, this fulcrum is in the upper cervical spine, at C2-C3. After age 8, the fulcrum shifts down to C5-C6, where it stays into adulthood. When you hear the term “internal decapitation,” it encompasses this movement of the upper cervical spine since the head swinging forward must happen in order for the ligaments to stretch and pull the head from the Atlas.
Another devastating injury that doesn’t show up on x-ray is called Spinal Cord Injury without Radiographic Abnormality (SCIWORA). This is when the spinal cord stretches because of the elasticity of the ligaments and cartilage in the spinal column. An x-ray will show normal bone alignment and no fractures, but the spinal cord may be irreversibly damaged. Remember that this bundle of fibers can only stretch up to ¼” before having catastrophic damage.
The evidence is clear. Rear-facing carseats protect the most fragile part of a developing child’s body: the head and spinal column. The 2018 American Academy of Pediatrics Policy Statement recommends rear-facing to the weight or height limits of the child’s carseat and instructs their pediatricians to counsel parents about rear-facing at each health visit. The National Highway Traffic Safety Administration (NHTSA) recommends rear-facing as long as possible.
Favorite Links
The American Academy of Pediatrics (AAP) has recommended since 2002 that after age 1 and 20 lbs., children should ride in a rear-facing convertible seat until reaching the weight limit of that carseat. They amended that policy in August 2018 to recommend rear-facing to the weight or height limits of the carseat.
Note how the legs fly away from the back of the vehicle seat during the rear-facing test on the left. In the forward-facing seat, the properly secured dummy bends nearly in half during the crash test. Photo courtesy Kathy Weber, ret., UMTRI, and SafetyBeltSafe USA.
2018 AAP Policy Statement on Child Passenger Safety, includes table summary of best practice recommendations and algorithm chart
2018 AAP Guidelines: rear-facing as long as possible, up to the limits of the car safety seat; includes virtually all children under 2 years of age and most children up to age 4
2018 AAP Technical Report: summary of evidence supporting best practice recommendations
The above video is a simulation comparing properly restrained 18 mo old models rear-facing to forward-facing in a 35 mph crash from the Children’s Hospital of Philadelphia Center for Research and Prevention (CIRP)
SafetyBeltSafe USA’s opinion on how long children should ride rear-facing. (How Long Should Children Ride Facing the Back of the Car?)
After reviewing studies from the U.S. and Sweden, a study published in the highly regarded British Medical Journal advises keeping children rear-facing until age 4. (www.bmj.com/cgi/content/full/338/jun11_2/b1994?view=long&pmid=19520728)
Leg injuries account for 28% of significant injuries faced by forward-facing children in crashes (Jermakian, J.S., et al. “Lower Extremity Injuries in Children Seated in Forward Facing Child Restraint Systems.” Traffic Injury Prevention 8 (2007): 171-179.)
This analysis shows how leg injuries are common among forward-facing children (Bennett, T.D., et al. “Crash Analysis of Lower Extremity Injuries in Children Restrained in Forward-facing Car Seats During Front and Rear Impacts.” Journal of TRAUMA® Injury, Infection, and Critical Care 2006;61:592-597
A tightly installed rear-facing carseat allows the vehicle and carseat to absorb crash forces and increases “ride down,” the amount of time it takes a body to come to a stop in a crash. The longer the ride down time, the less chance of injury. (http://www.car-safety.org/rearface.html)
Since there is almost always an element of forward motion in a side impact—such as when a vehicle is going straight through an intersection when it is struck on the side by a red-light runner—a rear-facing seat does a better job of keeping a child’s head contained within the safety of the seat. (http://carseatsite.com/whyrearfacing)
Evenflo is now requiring that children be age 2 before forward-facing in their convertible and combination carseats.
Approximately 75% of kids in Sweden rear-face until at least age 4. From 1999-2006, only 4 rear-facing children under age 4 were killed in crashes and their deaths were due to circumstances unrelated to the direction the carseat was facing (fire, drowning, excessive intrusion). During that same timeframe, 6 kids under age 4 facing forward in booster seats were killed; 3 of these crashes were potentially survivable crashes had the children been in rear-facing carseats. (http://www.bmj.com/cgi/content/full/338/jun11_2/b1994)
Anecdotal evidence suggests that infants around ages 10 mos.-18 mos. enter a fussy stage that makes it difficult to put them into any carseat, rear- or forward-facing. Many parents prematurely switch the rear-facing carseat forward-facing thinking that the child is objecting to riding rear-facing, when the child is objecting to being restrained at all. Visit the Car Seat Safety forums at www.car-seat.org and you’ll hear from other experienced parents regarding this phase.
The above video shows how the dummy stays contained in the seat during a rear-facing crash test. The tape on the dummy’s head is for measurement and doesn’t affect its head during the test.
This video is the companion video to the one above and shows a side view of the crash test. Note how little the head moves.
The above video shows a properly installed forward-facing seat. Note the seat belt stretch and how far forward the dummy bends.
The above video from Norway shows the differences between rear- and forward-facing carseats in an animated crash.
The above video from the Buckle Up With Brutus at The Ohio State University demonstrates the difference between rear-facing and forward-facing in crash tests.
If you need more convincing, take it from Dr. Marilyn Bull, a noted pediatrician from one of the country’s best pediatric hospitals, Riley Children’s Hospital in Indiana. This video was produced for, and used in, the current Child Passenger Safety Technician course.
Vehicle crashes are the number 1 killer of children. Protect your children to the best of your ability. Follow best practice.
Fantastic article on one of my soap boxes! I have posted in on my FB and website. Thanks!!
We need more RF seats on the market. There aren’t many to choose from here.
I also agree with others about the booster seats. Going by the current regulations, I would still need one now!
Amy, let me see if I can find someone with a copy of that study to see if they compared rf to ff leg injuries. What I do know is anecdotally, injuries do occur when a child is rf, but they are rare and tend to be from severe crashes.
One of the links to studies you title as “Forward-facing children are more likely to sustain leg injuries in crashes than rear-facing children.” But when I clicked over and read the abstract, it said nothing about the *comparative* rate of leg injuries in RF vs FF, only that the issue of lower leg injuries in FF needs to be addressed. Can someone who has read the full study, not just the abstract, weigh in?
Do you have any links that explain spinal development in toddlers? I’d like to see more about that. I want more fuel for discussing with peers. My daughter is still rear facing at 2.5 and will continue to. We have no issues to battle, i.e. our Radian fits well rear-facing in our car, she is happy as a clam in her seat, she doesn’t get carsick, etc. When I talk about extended rear-facing to my peers, they always have some sort of seemingly reasonable issue with it-issues my children have never encountered. Are they just projecting? I don’t know. It reminds me of someone above who said how absurd it would be to have your child in a booster through junior high. It’s only absurd because you as a parent assumes it is and teaches your child it is (and other parents teach their children that attitude as well). There is nothing inherently absurd about it…
http://www.youtube.com/watch?v=kvyIv9QVRBE is a great video that shows kids happily RF with their legs in different positions. It also shows a little boy, Joel, who received a broken neck from FF in a minor car accident. I think if we asked Joel how comfortable the back brace was that he had to wear for a very long time he would say not too comfy! Just my opinion of course.
I have also been on long car trips with children of all ages and I can safely say that their bladders give out long before their legs do. If you are taking a car trip with a child you should plan on making frequent stops to use the restroom and stretch everyones legs. Even my legs get sore sitting in the front seat.
No one will have to ask me twice whether I would choose my child complaining of sore legs and needing to stop the vehicle to stretch over my child complaining that her back brace or neck brace is uncomfortable and having no ability to alleviate her discomfort.
Also, we are currently trying to decide what to do with our own daughter about her car seat. I tried simulating the possible positions in which she could she could wind up. While the earlier example of sitting on a barstool without your feet propped gets uncomfortable (as in a forward-facing seat), so does sitting in a reclined position with your knees up like the kid in the picture.
Someone mentioned that our knees also bend when we sit straight up, but if you recline that position like a child in a car seat would be doing, the raised knees cause a loss of blood. I am a coach and have tried to sleep that way on many long, late bus trips. There is absolutely no feeling in your legs when you get up. I don’t really know what the best solution is….I suppose ever-adapting car seat models, but there’s only so much space to work with inside a car.
There is always a fine line between being safety conscious and going overboard. If my family had followed the guidelines about how long a child should be in a car seat and booster seat, I would have been in one (depending on which guidelines you consult) through the first year of HIGH SCHOOL!
Many of my 12 younger siblings would have been in the same unfortunate and humiliating position. We were certainly all forward-facing by 2 years old depending on the child, and my parents were indubitably the most overprotective I have ever heard of…you should have seen us trying to rollerblade with helmets, mouth guards, kneepads, elbow pads and wrist guards!
Here are some videos showing a forward-facing seat installed with LATCH. Note that belt stretch does occur with LATCH as well. Again, with forward-facing kids, we see lots of lower leg injuries as the legs fly into the front seats. If the seat is installed loosely, the injuries increase in severity since the head may also strike the vehicle interior.
http://ram.canadacast.ca/asxgen/transport/crash_tests/ISIstreams/Harness/Close/Windows_Media/TC09-129_16_UN9-232_close.wmv
http://ram.canadacast.ca/asxgen/transport/crash_tests/ISIstreams/Harness/Close/Windows_Media/TC09-213_16_UN9-228_close.wmv
(right view of child seat during impact taken from http://www.tc.gc.ca/eng/roadsafety/safedrivers-childsafety-programs-testing-harness-truefit-964.htm#c3)
I think the latch system would help prevent the car seat from being thrown all around. However I think even with the latch system the head and limbs of the child would still be forced violently forward causing considerable injuries.
Is there a video of front facing using the LATCH system? I have a friend who thinks because they used the seatbelt in that video that the same thing wouldn’t happen if it was the LATCH forward facing. Video link?????
My 7 month old daughter just graduated to her new Radian XTSL. 🙂 I did a lot of research and came to the conclusion that my child isn’t less important than the children of other countries like Sweden who have higher standards when it comes to child passenger safety. So my daughter will be RF until she is at least 45 lbs. Thank you for this site. It just gives me more hope and confidence that I am not the only one who cares about this issue.