Babies Archive

You may have heard that the American Academy of Pediatrics (AAP) recently updated their recommendations on rear-facing. As usual, there’s some good news and some bad news. As with our carseat reviews, we will discuss both the good and the not-so-good and try to offer some perspective lacking in national news coverage of this update.

The Good News: The basic recommendation for rear-facing has NOT changed. “The Academy continues to recommend that all children ride in a rear-facing car safety seat as long as possible, up to the manufacturer’s stated weight and length limits.” This updated guidance from the AAP now better matches NHTSA’s policy for consistency in messaging. The authors of CarseatBlog have strongly supported Extended Rear-Facing (ERF) for over 15 years and continue to support this practice.

ERF in 2003 – now off to college!

The Bad News: As we reported a year ago, a major study from 2007 was found to be flawed. This study was the main source of injury data to compare rear-facing child restraint systems (RFCRS) to forward-facing child restraints (FFCRS) in the USA, for children up to 23 months old. It was also the basis for the erroneous ‘Rear-facing is 5x safer’ statistic. Newer research found some contradictory data, causing the original study to be retracted. A revised study, by some of the authors of the original 2007 study, concluded, “Non-US field data and laboratory tests support the recommendation that children be kept in RFCRS for as long as possible, but the US NASS-CDS field data are too limited to serve as a strong statistical basis for these recommendations.” This led to the evolving AAP advice that, “…while the trend was for rear-facing to be superior to forward-facing for children under 2 years, the numbers were too low to reach statistical significance.” Definitely not as compelling as 5x safer.

More Good News:  The reason there is no significant real-world information is because the sample size of injuries to children in car seats is so low during the 22 year study period that there simply isn’t enough data to compare rear-facing to forward-facing conclusively. In fact, all these studies included less than severe injuries just to do an analysis, because there are so few data points for severe/fatal injuries to kids in child restraints. According to the revised study, “NASS-CDS data indicate an extremely low injury rate in children up to 2 years of age in both RFCRS and FFCRS.“ It turns out that both rear-facing and forward-facing car seats do a very good job of protecting children within the relevant age/weight/height limits!

Because the real-world injury data in the USA no longer supports that rear-facing is significantly safer for kids up to 23 months old, the AAP removed the portion of their policy statement recommending that kids remain rear-facing until at least 2 years old. Also, since the original study is retracted, we have to pretend that it never existed. Therefore, we can no longer claim that rear-facing is proven to be five times safer than forward-facing. We can’t even say that statistics prove that rear-facing reduces the real-world risk of serious injury for kids up to 2 years old [or to any age] in the USA.  On the plus side, the 2011 AAP policy on rear-facing to at least age 2 led to a lot of awareness about the safety advantages of rear-facing.

Let’s take a step back and examine the most recent AAP policy statements to put these minimum age recommendations in perspective. Fundamentally, the policies on rear-facing haven’t changed, except for the inclusion of minimums. For over 15 years, the AAP has continued to recommend that kids remain rear-facing to the limits of their car safety seat. In essence, “as long as possible.”

AAP 2018: All infants and toddlers should ride in a rear-facing car safety seat (CSS) as long as possible, until they reach the highest weight or height allowed by their CSS’s manufacturer. Most convertible seats have limits that will permit children to ride rear-facing for 2 years or more.

AAP 2011: All infants and toddlers should ride in a rear-facing car safety seat (CSS) until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of their CSS.

AAP 2002: Children should face the rear of the vehicle until they are at least one year of age and weigh at least 20 lb. Infants younger than one year who weigh 20 lb should still face the back of the car in a convertible seat or one that is approved for higher weights. For optimal protection, the child should remain facing the rear of the car until reaching the maximum weight for the car safety seat, as long as the top of the child’s head is below the top of the seat back.

Clearly, this is not the end for extended rear-facing. The retraction of the main study supporting ERF in the USA is indeed a big loss, but not a total surprise because this study had known flaws long before this retraction. Again, the fundamental guidance HAS NOT CHANGED. We still recommend kids remain rear-facing, preferably for 2 years or longer if they are within the rear-facing height and weight limits of their carseat. In particular, parents should pay close attention to the seated torso height limit of the rear-facing seat (which typically requires 1″ or more of shell above the head).

As always, we like to remind parents that these recommendations from the AAP are safest practice guidelines. They aren’t rules or laws. The rules a parent must follow are those printed in their car seat and vehicle owners manuals, on the car seat labels and in any relevant state law. CarseatBlog endorses the AAP guidelines for added safety. We also like to offer perspective by looking at the BIG picture. The biggest reductions in risk come from the following simple steps:

1. Drive unimpaired and undistracted
2. Keep all passengers properly restrained according to the instruction manuals and state law
3. Kids under 13 years in an appropriate rear seating position

So please, buckle up and drive safely!

See our Rear-Facing Links Guide for additional information.

Updated Recommendations for Children in Carseats and Boosters

A revised policy statement on Child Passenger Safety from the AAP (American Academy of Pediatrics) was released today. The most significant change is the removal of the age 2 minimum recommendation for forward-facing.  The updated policy keeps the basic wording to recommend that children remain rear-facing until they reach the maximum weight or height allowances of their carseat. This revision aligns AAP’s policy with NHTSA’s current recommendations which also suggest using your carseat to the limits before transitioning to the next stage/category of seats.

The table below outlines the updated Best Practice Recommendations from the AAP.

The policy revision is a direct result of the retraction of the 2007 Henary study which we now know was flawed. Unfortunately at this moment, we do not have enough data to definitively say how much safer rear-facing is compared with forward-facing. Also we can no longer point to a specific age at which to make the transition from rear-facing to forward-facing. We acknowledge that this revision will cause some confusion to parents and caregivers who have previously been told that the AAP recommendation was to rear-face to a minimum of 2 years. Currently there are 11 states with laws that mandate rear-facing to age 2, and there are also carseats on the market which also mandate a 2-year age minimum for forward-facing. If you live in a state that requires rear-facing to age 2, or if you own a product with a 2-year age minimum for forward-facing then you must follow the guidance of your state laws and/or your manufacturer’s instructions.

The AAP used a data-driven approach in revising this policy. In the absence of statistically significant field data to support the previous rear-facing to age 2 recommendation, they felt it was necessary to update their current policy.

We understand that evolving information can be hard sometimes and the lack of good data is frustrating. On the bright side, the reason that we don’t have enough data on kids being injured in carseats, rear-facing or forward-facing, is because carseats are doing a great job of protecting children in crashes. We encourage researchers and manufacturers to continue important research on this and a variety of other subjects that relate to child passenger safety. Here at CarseatBlog we will continue to focus our efforts on educating parents and caregivers on proper usage of carseats and boosters.

Putting a newborn baby in a car seat is daunting even in the best of circumstances. They are just so tiny and fragile, the buckles on the seat seem so huge and it often feels like you’re just going to smush (technical term) their insides when you tighten the harness. As they grow, they feel less breakable, but it seems there’s always something new to worry about when it comes to car seats.

One of the most common questions I see on parenting and car seat groups is regarding head slump, typically in forward-facing kids or in older rear-facing children. There are new aftermarket products coming out each day to address this issue, but as a Pediatric Physical Therapist and a CPS Technician, I have some grave concerns that these “solutions” to head slump might be much worse than the problem itself.

What is head slump?

You know when your husband sits next to you on an airplane and immediately falls asleep while you are stuck alone, anxious and bored out of your mind for the next 3 hours? (No? Just me?) Well, that moment when they’re so deeply enjoying their abandonment nap that their head falls forward is “head slump”.

Head slump is when the chin moves towards the chest in a moment of forward flexion of the cervical (upper) spine. It is most common when a person is sleeping upright, and to an adult, it’s pretty uncomfortable. Adults are not terribly flexible and some of us carry a tiny little bit (okay, a ton) of tension in our necks. But thankfully, our kids don’t. Their necks are more mobile than ours and much less prone to tightness from tension, so the forward flexed head isn’t usually painful for them. The person sleeping on the airplane isn’t in any danger from their head slump position and likewise, for most kids, it’s really a non-issue.

When is head slump something to worry about?

The first and most common scenario where head slump is a real problem is in a newborn. The airway in a newborn baby is tiny, about the diameter of a drinking straw, and often it’s a little more flexible than an adult’s, meaning it’s easier to partially block or collapse. Another reason head slump can be concerning for a newborn is that they may not have the neurological drive to reopen their airway. That is, their brain may not be developed enough to realize that it’s being deprived of oxygen or to tell the muscles to do something about it. Finally, because newborns have proportionally large heads on tiny neck muscles, even if they have the drive to lift their heads, they often lack the strength to make that lift against gravity.

Image from Journal of Emergency Medical Services

The other situation where head slump is a concern is in older children who do not have adequate head control. These are typically children with medical diagnoses of some sort and the problem is essentially the same as in a newborn – if a child cannot lift and maintain their head upright against gravity, then they need to be positioned to make sure that head slump does not occur. The same goes for babies with tracheomalacia, where the trachea is not as rigid and may be more prone to collapse.

These two groups aside, head slump is not a problematic position for typically developing children and older babies. These children have wider airways, the ability and awareness to lift their heads if they’re not getting adequate air, and the position itself isn’t inherently dangerous for the neck. There’s not a universal age where this happens, but once baby can fully lift their head and hold it up to look around for a few minutes during tummy time, they’re likely in the clear.

What should you do about head slump?

I remember the good ol’ days when my neighbor friends and I would climb into their old truck in their driveway and pretend to drive to faraway lands. We would each take turns “driving” the old stick shift and using our imagination, pointing out landmarks and making tire squealing noises as we yanked on the steering wheel. I think back and wonder how I’m alive today; that truck could have easily slipped into neutral and we would have rolled into the street or over one of us as we played or did one of our other insane things (I did not partake in jumping from my roof into the pool, but my friends, on the other hand . . .). But even in the good ol’ days, kids were dying in hot vehicles, just as they are now. They’re dying on a weekly basis now, sometimes daily, and we need to change this.

People who live in hot climates know this isn’t a modern phenomena, though with the advent of social media where news travels at lightning speed, hot vehicle deaths become known about within moments. Rear-facing carseats also have contributed to an increase in these deaths, though kids have fallen asleep in cars since there have been cars, so it’s hard to place the sole blame there. The old “out of sight, out of mind” adage is often mentioned with rear-facing seats, but it’s much more than that.

We know the human brain is fallible; it forgets things, especially when there’s a change in its routine. The brain likes to fly on autopilot. Think about what you grab before getting in your car: your keys, cellphone, and wallet. One day you also want to take a bottle of water, but your wallet is on the kitchen counter instead of next to the door with your keys and water. You’re still taking 3 things with you, right? You take the keys, water, and cellphone because your brain expects you to take 3 items. You get to your destination and realize you don’t have your wallet. Or maybe the time you left a drink on top of your car because your hands were full and you needed to unload items into your back seat? Recognizing this is the first step in taking away the “It can never happen to me” mentality because guess what? That’s what the parents who forgot about their kids thought too. And before you cast stones on parents who do accidentally leave their kids in cars and proclaim, “I’d *never* forget *my* child in a car,” read this article. It’s so important, I’ve linked it twice in the same paragraph.

We also need to dispel this idea that the vehicle is a babysitter. This is NOT proper parenting practice and needs to STOP. Do NOT leave your child in the car without supervision while you run into the store/bank/cleaners/hair salon. Just don’t. This is 2017 not 1977 and we know better now. I’m going to judge you on this one. And call the cops. We’ve had too many instances of kids who can’t open their carseat buckles bake to death in their carseats, who can’t open car doors because they’re locked, who are stuck in stolen vehicles—I can go on.

Vehicles are tools to get us from one place to another. We wouldn’t let our kids play with a power tool, right? When our vehicles are parked, they should be locked and the keys put in a place where kids can’t access them so they don’t accidentally get stuck in them (otherwise known as vehicle entrapment). Think like your child for a moment: perhaps they left a crayon or marker in the car and want to go get it. So they go to the car, climb in and locate the item. But the child locks are on and they can’t open the door—they’re stuck in the back seat now! Panic sets in and it’s hot because the car’s been in the sun or hot garage. Maybe there’s stuff on the center front console and your child sees it as too big a wall to climb over. Since a child’s body heats up 5 times more quickly than an adult’s, their thinking can be foggy very quickly and they can become overheated in minutes. If you can’t find your child, check bodies of water first (including neighbors’ pools and ponds), then check your vehicle thoroughly.

Don’t forget to ask your childcare provider to follow up with you immediately if you don’t drop your child off at your prearranged time. With our technology now, it takes only a minute to send out a text blast at even the largest daycares. Even an hour can make a difference, so it’s important to confirm drop off times quickly.

What about alarms? Evenflo has the SensorSafe Technology™ on certain carseats (we previewed the Embrace DLX with SensorSafe here) that chimes when the 2008 or later vehicle is turned off (or when the chest clip is opened while the vehicle is in motion). GM offers a Rear Seat Reminder on all new 2017 Acadia models and will be expanding it to more Buick, Cadillac, Chevrolet, and other GMC models for 2018 models. A smart pre-teen from Texas created an alarm that blows a fan after a neighbor’s 6 month old died in a hot car. Can we rely on alarms? Do they give us a false sense of security or will we eventually succumb to warning fatigue? The thing about humans is that we’re lazy and unless we’re highly motivated, we’re going to start to ignore the sounds and reminders, especially if they’re . . . routine.

I’d like to see mainstream media take these vehicle heatstroke deaths and make half as big a deal out of them as they do most news stories. Having been in a grassroots organization for years trying to get media coverage for child passenger safety, it’s frustrating not to have this topic taken seriously. Word of mouth only goes so far in getting the message out. But of course, there are still a lot of people out there who don’t think keeping children safe in and around vehicles should be a priority so it’s not surprising this topic doesn’t rank higher in the news cycle. I wonder how many kids have to die until it does?

Infographic provided by noheatstroke.org, run by meteorologist Jan Null. He keeps this website up-to-date with the sad statistics and other scientific data regarding hot vehicles.