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An Open Letter to the Executives at Modern Family

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To Whom It May Concern-

I want to start out by saying that I love your show. I really do. I have loved it since it came on the air years ago and we watch it religiously, even though we don’t have cable or an antenna, because we love it so. But I would be lying if I didn’t also say that I am at the end of my rope with a significant oversight that just keeps showing up: child passenger safety.

The first time it happened, I don’t think it even really pinged my radar. Probably because I didn’t have kids and didn’t know anything about car seats (which I suspect is true of whoever oversees things on this show). But now looking back, I realize how big of an error it was.

The first time was when Lily, the daughter of modern family 1Cam and Mitchell, was a baby. It’s possible that she was over the age of 1, both in real life and in the show, but she is very small and it looks a whole lot like she’s forward facing in a rear facing only seat. I’ll admit I could be mistaken and will forgive them this one if I am (even though she would be substantially safer rear facing), since forward facing after age 1 and 20 pounds is legal in Los Angeles, but it’s where my mistrust began.

modern family 2The next time was when Lily was a bit older. This one nearly snuck by me, but if you look closely, Lily, who in no way, shape or form, should be in a booster, is not belted properly in her seat. If I had to guess, I’d say that the seatbelt is over the armrest instead of under it, but either way, the belt fit is not correct. Picky? Maybe. But as most of you know, child passenger safety is one area that we ought to be picky about. The seat belt should be contacting the middle third of her clavicle and low on both hip bones, as those are the strongest boney parts of the body and are most able to withstand the crash forces. Complaining about where the belt is now might seem picky, but it could cause really significant injuries.

And don’t worry, I’m about to get less picky.

Mythbusters: Are bent legs in a car seat developmentally dangerous?

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I had the great fortune of helping out at a fantastic car seat check event a few weeks back where I met with 4 different families. While their car seats and children could not have been more different, all 4 of them asked me the same question: isn’t having bent legs (while rear facing) bad for a child’s hips?

I see this quite a bit on the internet- inevitably whenever a news source writes about a new law or rear facing evidence, someone comments that sitting with the legs bent is going to forever stunt the growth of a child or cause hip dysplasia or otherwise damage a baby’s developing bones. So it seems like it’s time to delve into the research and maybe dust off my physical therapy degree.

Myth: Having legs bent or in a frogged position when rear facing can cause damage to the hip/knee joints and associated bones.

Quinn in Fllo rf

First, let’s look at hip dysplasia. This is obviously a concern for many parents of infants. Hip dysplasia occurs when the hip “socket” is not deep enough, typically at birth. This is common in babies who are breech, first babies and in multiples. When babies have dysplasia, the first line of treatment is a harness. This harness attaches to the baby’s trunk and a series of straps pull the hip into flexion and abduction, basically a frog leg position.

Which is oddly similar to how big kids sit while rear facing. So it stands to reason that if the child sits in the position a hip dysplasia harness would hold them in rear facing, that there’s no significant risk of hip dysplasia from extended rear facing. Also worth noting is that by the time kids reach the age where their legs are scrunched, they are typically standing/walking, which helps deepen that hip socket and vastly reduces the risk of hip dysplasia.

oliver rf bvct 1 Infant in a Pavlik Harness Source: http://www.wheatonbrace.com/products/wpharness.html http://www.lpch.org/photos/greystone/ei_0239.gif http://catalog.nucleusinc.com/generateexhibit.php?ID=4574&ExhibitKeywordsRaw=dysplasia&TL=1280&A=2

Okay, so I feel like we’re good on the dysplasia part. So what about bone growth?

Mythbusters: 5-point Harnesses Are Safer than Boosters for Older Kids

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Is a 5-point harness safer than a booster seat and seat belt for an older child?

This is a myth I’ve personally wanted to confirm/bust for quite some time, so I decided it was time to do the research and try to find a definitive answer. It seems to be a common question from a lot of parents and there has not been one final declaration either way, so today we’ll take a look at the evidence and try to come to a consensus. No promises that we’ll find a real answer though.

Myth: 5-point harnesses are always safer than a 3-point seat belt for older kids.

So right off the bat, I want to make a few points- by “always” in the myth, I mean for neurotypical, booster age (let’s say age 5 and up) children and adults. It’s clear that 5-point harnesses are safer for children who cannot sit in the proper position for an entire car ride, but for adults and mature children, we need to look at the evidence to see if there’s an advantage either way.

Transport Canada - Integrated harness and booster NCAP test

Photo Credit: Transport Canada

First, let’s look at the studies that have compared properly fitting seat belts (meaning in a booster for kids age 5 and up) and 5-point harnesses in similar crash circumstances:

That’s right, there aren’t any. Zip, zilch, zero. So that will make this a bit more challenging.

There are a number of studies that compare children in 5-point harnesses to seat belts alone and a number that compare children in belt positioning boosters to seat belts alone, and even one Canadian study that compared boosters with a 5-point harnessed seat but with a dummy that was heavier than the weight limit of the harness. But none that compare children in 5-point harnesses to children in belt-positioning boosters for older kids.  One study did show a modest benefit of a 5-point harness over boosters for 3-year olds, but showed much smaller benefits for 4-year olds and concluded, “The results for any type of injury support the recommendation for graduation at 4 years or about 40 pounds in general, although it may be the case that more severe injuries are better prevented by CRS (Child Restraint System with harness) even at 4 years old.”

So despite the past research, we don’t have any firm evidence to tell us whether older kids (5+) are safer in boosters vs. forward-facing 5-point harnesses. I’m sure it will be no surprise that in the studies that exist, both 5-point harnesses and high back belt-positioning boosters both reduce the risk of injuries to children as compared to seat belts alone. But that doesn’t help us here.

So we’ll take a step back and look at the established pros and cons of each restraint type.

5-point Harness (forward-facing):

-Pro: When used correctly they almost completely eliminate the risk of ejection in all types of crashes.
-Pro: They disperse the crash forces over more areas of the body, which equals less force in each area.
-Pro: They keep a child optimally positioned throughout a car ride, even when asleep.
-Pro: They have a tether that reduces forward head excursion (as compared with non-use of tether).
-Con: The seat must be installed properly with less than one inch of movement with top tether for best practice.
-Con: The harness must be appropriately tightened (to pass the pinch test), otherwise child will experience greater head excursion increasing the chances that the head will strike something inside the vehicle.
-Con: The harness has a weight limit and a height limit
-Con: In holding the body against the seat, the neck may incur increased forces in a frontal crash.

Belt-Positioning Booster with 3-point Lap/Shoulder Belt:

SK300 in booster mode - great belt fit-Pro: Seat belt retracts on its own (ideally), so there’s less risk of it being too loose (in appropriate riders).
-Pro: No complicated installation process.
-Pro: No weight limit on seat belts.
-Pro: Backless boosters will have less head excursion in frontal crashes simply because the head is starting off in a more rearward position initially.
-Pro: A lap/shoulder seatbelt allows the neck and spine to move together more easily (compared to 5-pt harness)
-Con: Kids can move out of optimal position easily and frequently, especially while sleeping or leaning forward to look at a device.
-Con: Some seats don’t have LATCH to hold them in place while loading or unoccupied
-Con: More variables involved (as compared to properly installed 5-pt harness) that cannot be accounted for pre-crash. E.g., what point in the crash sequence the retractor locks. Does the child “roll out” of the shoulder belt during the crash?
-Con: Seatbelts provide fewer points of restraint with the body, which may mean greater chance of head excursion, ejection and submarining under the lap belt in severe crashes. Especially a concern in far side impacts, rollovers and multi-impact crashes.

Well. That didn’t really help much, now did it?

forward-facing crash testWe unquestionably need more investigation on head/neck forces in 5-point harnesses versus 3-pt seat belt. When a body is harnessed into a seat, the only real free movement comes above and below the harness- so we see the neck snap forward (why rear facing is recommended for younger kids) and the arms and legs go flying forward. It’s a lot of pressure on the neck, which isn’t ideal for children before their spine is fully ossified (converted from cartilage to bone).

In a seatbelt, there is more rotational movement of the body around the shoulder belt, which may, theoretically, reduce the forces acting on the head and neck because the spine is also moving. What we don’t know is if it’s a meaningful decrease in neck forces or if this theory even pans out in real life, especially for older kids. And, even if there is a meanfuling decrease in neck forces in a 3-pt seat belt, is it significant enough to offset an increased risk of ejection or partial ejection in a booster – especially in side impacts and rollovers?

So, I realize this is anticlimactic, but:
BUSTED, PLAUSIBLE OR CONFIRMED?

Ummmmm, PLAUSIBLE?

Harness, Highback booster, backless booster

There’s no real answer here, which is as frustrating for me as it is for you, I can assure you. I think the big takeaways are:

1) Children who cannot sit properly in a seatbelt through an entire car ride (even when asleep) NEED to be in a 5-point harness, even if we find out that seat belts are better in some ways.
2) Proper use of both 5-point harnessed seats and belt-positioning boosters greatly reduce the risk of injury in a crash.
3) We need someone to really study this.

I promise to update when/if more information becomes available. In the meantime, I’d love to hear what other people have found when researching this themselves.