When I’m not carseating, I work as a physical therapist in a pediatric setting. As you can imagine, there tends to be a lot of overlap with carseats and my “real” job, but you might be surprised to hear that the most common intersection of the two has to do with babies who are born with a tight neck muscle.
Torticollis is a condition where a muscle in one side of the neck gets tight, usually because of the position of the baby in utero. Torticollis tends to cause babies to have a strong preference for rotating the neck in one direction and tilting the head in the other direction. It’s most common in first babies, twins and babies of petite mothers (all because of space constraints in utero). One of the biggest issues that results from torticollis is that babies can end up with an asymmetrically flat head, known as plagiocephaly. For some kids this is mild and it improves on its own; for others, they may require a specially made and adjusted helmet to help the head round out.
In virtually every evaluation for a baby with torticollis and plagiocephaly, parents (understandably) express concern about what, if anything, they can do in the carseat to keep their baby’s head from tilting or rotating. And sometimes they’ve already tried things- usually aftermarket inserts, sometimes wash cloths, when the secret is, you probably don’t need to add anything.
As we know, adding anything to a carseat that didn’t come with the seat (or was not expressly crash tested with the seat and approved by the carseat manufacturer), is generally not a good idea. It will void the carseat warranty, it goes against every manual (which, in most states makes it illegal) and it may potentially result in injury in a crash. So, basically what I’m saying is, even if you’re worried about your baby’s head shape, please don’t put aftermarket products in the carseat. They won’t help much and they may put your child at increased risk.
Truthfully, unless your baby spends hours, like, literal sustained hours each day in a carseat, the seat isn’t really what is causing the flatness to develop. So fear not, the carseat is just fine the way it is. I know that at times seeing baby’s head tilted or rotated in the car can be troubling. But rest assured that a tilt to the side or rotation isn’t unsafe. The only position that is worrisome is if baby’s chin tips down onto its chest, which in small infants can compromise the airway (and is probably a sign that your child’s carseat isn’t reclined enough- find a CPST in your area to have it checked out!).
If you’re worried about baby’s head falling to the side, you can try rolled up receiving blankets on either side of baby, placed after baby is buckled. I will be honest that I don’t necessarily love this set up because baby could rotate their head and spend a sustained amount of time with their face in a blanket, but it is a parental decision and if you feel strongly that something needs to be done to keep baby’s head in midline, this is your safest option.
If you want to make sure that baby rotates their head to their non-preferred side, you can definitely make that happen in the carseat. If your seat allows it, and several explicitly don’t, so consult your manual, you can hang a soft toy (like, literally made of a material and so soft you would throw it directly at your child’s head and they wouldn’t be injured) from the handle, offset towards the side you want baby to look. I had one creative parent who tied a few ribbons on the non-preferred side of the handle. They presented no risk to baby, but were bright and got baby to rotate his head that way. Other options include, if you have another backseat passenger that baby will like to look at, seat that person on baby’s non-preferred side. Or if baby is not sitting in the middle seat, and you can get a good installation and feel comfortable with baby outboard, place their seat so that they have to look towards their non-preferred side to see out the nearest window.
Most of all, any baby, but especially a baby with torticollis, will benefit from the least possible amount of awake time in any baby device that puts pressure on baby’s head like a swing, bouncy seat, cradle or carseat. Babies need a lot of floor time when they’re awake so they have room to learn to roll and sit and crawl and they especially need time on their tummy to strengthen their necks, which will help correct torticollis.
If you think your baby may have torticollis or plagiocephaly, talk to your pediatrician about it and see if a referral to a physical therapist in your area might be appropriate. And if you’re worried about carseat positioning with a baby with torticollis and/or plagiocephaly, find a CPST near you to check your set up and see if there’s anything else that can be done to keep baby safe and keep baby’s head nice and round.
Evidence-based justification for extended rear-facing
It’s all the rage among parents nowadays: extended rear-facing. If you’re turning your child to face forward before age 2, 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—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. According to this study, rear-facing children 12-23 months are 5.53 times safer in a side impact than forward-facing children and there’s no indication that safety magically disappears at 24 months.
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 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 March 2011 to recommend rear-facing to age 2 or until they reach the “highest weight or height allowed” by that convertible 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.
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)
Rear-facing carseats provide excellent protection in side impacts as well. Because there’s usually a vehicle moving forward, as through an intersection, that element of forward motion can easily throw a child’s head clear of the carseat if he’s forward-facing. If rear-facing, his head will stay protected inside the carseat. (http://www.carseatsite.com/rf.htm)
Infants and young toddlers have spines made of soft bone and cartilage that doesn’t begin to harden until around age 3. As a result, the spinal column can stretch up to 2 inches; however, the spinal cord will rupture after being stretched after only ¼ inch. This damage cannot be repaired. (http://www.carseat.org/Technical/tech_update.htm#rearfacFF)
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 Brutus at 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.
We are so excited about this new product, which will be available Spring 2017! The UPPAbaby MESA is already one of our favorite premium infant carseats (it’s one of our Editors’ Picks from our Recommended Seats List). And, soon chemical-conscious parents in North America will have the option to buy a MESA model with a merino wool blend cover that is naturally flame retardant!
This new model, called “Henry/ Blue Marl” (which is actually more grey than blue), will be the first chemical-free infant carseat trim cover! You’re going to shell out $50 more for that particular fashion, but if reducing your child’s exposure to certain chemicals is high on your list of priorities, we don’t think an extra $50 for a wool blend cover that is naturally flame retardant is unreasonable.
Aside from being the “Greenest” carseat, MESA is packed with safety and convenience features. The base is a breeze to install with lower LATCH connectors. Seatbelt install is easy too thanks to the lockoff on the base. This model fits preemies and small newborns well. And of course, it’s compatible with the wildly popular UPPAbaby VISTA & CRUZ strollers if you want to create an ultra-premium travel system. Check out our UPPAbaby MESA Review for the full scoop.
Why Merino Wool?
Merino wool is the only fiber that is naturally flame retardant. For this reason organic mattresses have been made with wool for years. Merino wool is also well-known for being a wicking fiber which makes it comfortable in both warm and cool weather. This is not the itchy wool sweaters of your youth – merino wool doesn’t feel like traditional wool and it won’t bother even the most sensitive baby skin. We all touched the Henry cover and agreed that it felt smooth and lovely.
Why do most carseats have chemical flame retardants added?
Unfortunately, the fact is that an antiquated federal law requires manufacturers to meet strict flammability standards and it’s very difficult (although clearly not impossible) to meet those standards without adding chemical flame retardants. However, manufacturers do have a choice as to which chemicals they use and how they use them.
UPPAbaby deserves huge kudos for finding a way to meet the flammability standards without adding flame retardants to the cover! They also used energy-absorbing EPP foam (instead of EPS foam) because EPP doesn’t require additional flame retardants. As a side note, all current (non-Henry) MESA models meet the flammability standards without using brominated or chlorinated chemicals (e.g. PBB’s and PBDE’s), which are considered the worst offenders.
“Henry” will be arriving early Spring 2017. We will update the ETA as we get closer to the launch date and have more specific information.
MSRP for “Henry” fashion will be $349.
So, what do we think?
We were so impressed, that we awarded UPPAbaby with one of our exclusive “Shut Up & Take My Money” Awards for Best New Product at the 2016 ABC Kids Expo! Congrats to UPPAbaby for being the first to market with a naturally flame retardant carseat cover! We hope to see many more of these in the future.
The Safest Infant Carseats: Best, Better or Basic? How do infant seats compare?
Today, Consumer Reports released their second round of infant carseat ratings using their new test methodology for evaluating infant child safety seats. We feel these ratings are likely to be a big step forward and should help parents to compare the crash safety of carseats. In the long term, just like the 5-star rating system from NHTSA and the IIHS Top Safety Pick ratings for automobiles, more rigorous testing often leads to better product designs in the future.
Why did Consumer Reports create their own crash test for child restraints?
Consumer Reports wanted to provide consumers with comparative information on carseats. By developing their own crash test, the goal was to determine which carseats offered an extra margin of safety in certain crash conditions simulated by the new tests. We know all carseats sold in the U.S. should meet federal safety standards but we also know all carseats aren’t the same. The goal here was to determine which seats could hold up well even under tougher crash test conditions that were also more “real world” than the current tests.
How is this test different from the government’s FMVSS 213 crash test?
The Consumer Reports crash test was developed to be more rigorous than the current federal safety standards. They also designed the test with more real world vehicle conditions in mind. This new test is performed at an independent, outside testing facility. It uses a contemporary vehicle seat with a lap/shoulder seatbelt and a floor below it, unlike the government’s FMVSS 213 crash test which has a 70’s era back seat test bench with lap-only seatbelts and no floor. There is also a “blocker plate” installed in front of the test seat to simulate the interaction that occurs between the carseat and the front seat in a real crash. This is important because in the real world we know children are often injured when they come into contact with the back of the front seat during a crash. Consumer Reports also chose to run their tests at 35 mph; the government’s crash test is 30 mph.
What is the rating scale?
The crash protection ratings will indicate a “BASIC,” “BETTER,” or “BEST” score for crash protection. The rating is based on a combination of injury measures. While we don’t know exactly where they drew the line between best and better, we do know that seats receiving a “best” rating for crash protection performed statistically better than other peer models for crash performance.
A seat can be downgraded to a “basic” rating if there are repeatable structural integrity issues or if the dummy records injury measures that are considerably higher than the other peer models tested. Seats with a “basic” rating are still considered safe to use because they do meet all the safety standards in FMVSS 213. Please try to keep in mind that these are VERY challenging new tests and there will always be some designs that outperform others.
CR also gives each seat a separate overall numeric score which is based on its crash protection rating and other factors like ease of installation with seatbelt or lower LATCH anchors and ease of use. Seats with high overall scores will have a “better” or “best” crash protection rating plus they are considered easy to install properly and easy to use correctly.
Below we have listed the crash protection rating for the infant seats that received either a “Best” or a “Basic” rating for crash protection. If you want to see the full ratings for all the seats they tested, which include 22 additional models in the “Better” rating category (plus all the overall numeric scores and comments), they are available only to subscribers. An annual online subscription to ConsumerReports.org is $26.
Infant Carseat Ratings
Not surprisingly, their top overall performers (combination of crash protection plus ease of installation and ease of use) are the Chicco KeyFit & Chicco KeyFit 30 models, which are also on our list of Recommended Carseats.
We note that the Asana 35 DLX (our review of the Asana is coming very soon), Cybex Aton 2, Cybex Aton Q, & Nuna Pipa were all tested using their load leg feature. Thanks to the load leg, these seats were all top performers in crash protection. Unfortunately, a load leg cannot be used on the government’s FMVSS 213 crash test sled, as that sled does not have a floor.
Below is a table of the infant carseat models which received a “Best” rating for crash protection, as well as those that only received a “Basic” rating.
If you’re worried about baby’s head falling to the side, you can try rolled up receiving blankets on either side of baby, placed after baby is buckled. I will be honest that I don’t necessarily love this set up because baby could rotate their head and spend a sustained amount of time with their face in a blanket, but it is a parental decision and if you feel strongly that something needs to be done to keep baby’s head in midline, this is your safest option.
