News Archive

Rear-facing is no longer 5x safer. Really?

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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 guidelinesThey 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.

2018 Revised American Academy of Pediatrics (AAP) Policy – Child Passenger Safety Best Practice Recommendations

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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.

Calculating the Cost of Saving Lives

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The Centers for Disease Control and Prevention has recently released a new version of a tool to help people (legislators, law enforcement officials, advocates, etc.) determine what kind of impact various motor vehicle laws and enforcement practices would have on saving lives, and what the overall cost/savings would be.  The tool is called the Motor Vehicle Prioritizing Interventions and Cost Calculator for States—but you can call it MV PICCS (pronounced “picks”) for short.

When you first open the calculator, you see a map of the United States with each state color-coded according to its 2015 vehicle death rate. You can then select a state and select various laws/fines/enforcement options that might reduce motor vehicle fatalities and injuries. You can enter a specific budget, and you can also determine whether to have fees and fines from those interventions rolled back into the cost of implementation.

Then the calculator will show an estimate of how many lives will be saved, how many injuries will be prevented, the cost of enforcement, the fees/fines produced, and the overall cost to the state.

I decided to play around with the calculator a bit. First, I selected my current home: Illinois. Illinois already has a very low vehicle death rate (7.8 per 100,000 people). One thing that really bugs me about Illinois, though, is the lack of a motorcycle helmet law. Of the motorcycles I see on the road, I’d say around 25% have riders with helmets. My small community alone has a few motorcycle deaths each year, and I often wonder how many of those could be prevented with helmets.

So on MV PICCS, I checked the option for motorcycle helmets and the option to use fees and fines to offset costs. I then hit the “run model” button, but I got a message saying that it couldn’t select any interventions given a budget of $0. So I entered a budget of $1,000,000, and it said it couldn’t select any interventions given a budget of $1,000,000.

I decided to keep my $1 million budget, but, in addition to the motorcycle helmet law, I checked “Increased Seat Belt Fine” and “In Person Renewal” (for drivers license renewals of those aged 70 or older). This time it did calculate, and it showed 102 lives saved (42 from helmets, 47 from increased seatbelt fines, and 13 from in-person renewal). The overall cost to the state would be $-3.85 million, meaning the fines and fees would greatly outweigh the implementation costs.

Then I decided to play with Wyoming, the state with the highest vehicle death rate: 24.7 per 100,000 people. For Wyoming, I selected seven interventions (Motorcycle Helmet, License Plate Impoundment, In Person Renewal, Increased Seat Belt Fine, Primary Enforcement Seat Belt Law, Seat Belt Enforcement Campaign, and Sobriety Checkpoints.) I also entered a budget of $1,000,000.

MV PICC calculated 40 lives saved and 2,535 injuries prevented. The overall cost to the state would be $840,000.

(It’s also important to remember that laws and driving practices aren’t the only contributors to vehicle deaths. As we’ve reported before, fatality rates are often higher in rural areas, due in part to increased response time for emergency services. States like Wyoming and Montana could certainly reduce their fatality levels with the enforcement of certain laws, but that won’t change issues like terrain and response times.)

While the calculator was kind of interesting to play around with, and while it might provide a decent cost-benefit analysis for some scenarios, I felt like it was a bit too simplistic. I finally figured out that its estimated cost to Illinois to implement a motorcycle helmet law would be $3.5 million. There would be some additional costs in the first year for sure (to update driver’s handbooks, update websites, publicize the law, update law enforcement), but surely the long-term costs wouldn’t be anywhere near that high. It would be nice to see a 5- or 10-year cost estimate.

I also felt the calculator lacked a lot of important options that play huge roles in motor vehicle deaths. There are no options for enhanced child restraint laws or enforcement. There is no option to lower speed limits. There is no option for implementing/enhancing graduated driver’s license programs for teens. And, perhaps most glaringly, there is no option for enhanced laws or enforcement surrounding distracted driving.

The MV PICCS is a decent starting point, but it’s not all-encompassing. Without having a more comprehensive list of interventions and a longer-term view of costs, I’m not sure how useful the calculator will actually be. For finding quick statistics and getting a general overview, though, I can see how it could be a handy tool.

Consumer Reports Releases New Booster Ratings

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Consumer Reports has just released ratings of 51 boosters, including high-back, backless and models that convert from high-back to backless.  In their article, CR gives some great advice for parents:

First, they recommend not moving your child to a booster until she or he has reached the height or weight limits of the forward-facing 5-point-harness system in the current car seat.  CarseatBlog recommends the industry standard advice for a minimum of 4 years and 40 pounds before kids begin to use a booster.  Some organizations now recommend 5 years, especially for squirmy kids that cannot remain seated properly.

Next, CR also advises that laws for booster use can vary from state to state, so be sure to find out what the law says in the state where you are using the booster. They also warn that state laws don’t always reflect best practice, or might be based on weight rather than age/height. CR and the American Academy of Pediatrics (AAP) recommend that kids use boosters until they are at least 4 feet 9 inches tall and 8 to 12 years old.  We agree!  Depending on vehicle and child, some kids will not fit correctly without a booster until well beyond 8 years old.  How can you tell if your child still needs a booster?  Have them take the 5-Step Test.

The full ratings for boosters from Consumer Reports are available to subscribers.  CR’s top ranked high-back to backless boosters are the Evenflo Big Kid models starting around $30.  The Chicco KidFit and KidFit Zip are top performing models in all CR’s testing as well.  A CarseatBlog Editors’ Pick, the Graco Affix, is also among the higher rated models in CR’s evaluations.  Among high-back only models, the top performer in their testing is the Cybex Solution, though these are currently difficult to find at retail and among the most expensive on the market.  For backless models, the Harmony Youth Booster was the top pick.  It’s also a CarseatBlog Editors’ Pick and a bargain for under $11 at Walmart.

Most models did well in Consumer Reports evaluations.  We note that Consumer Reports had low ratings for some compact/budget backless boosters.  Notably, the Mifold booster had the lowest score in their ratings.  CR stated, “… kids using the Mifold may still be tempted to slouch because it lacks a cushion for their knees to bend comfortably over.”

In addition to CarseatBlog’s expert staff picks for Recommended Boosters, we also advise parents to check out the IIHS Booster Evaluations as well.  Even models highly rated by CarseatBlog, Consumer Reports and the IIHS may not work well for you, with your child, in your vehicle.  So, as always, we recommend purchasing from a store with an easy, free returns policy just in case it doesn’t work well for any reason!