AAP Updates Car Safety Seat Recommendations for Children

Family Physician Offers Tips for Sharing Information With Parents, Caregivers

September 21, 2018, 11:08 am Michael Devitt – Regardless of what the bigwigs in the real estate and oil industries may tell you, children are our most important natural resource.

"Car crashes remain a leading cause of death for children," said Benjamin Hoffman, M.D., lead author of the new policy statement and chair of the AAP Council on Injury, Violence and Poison Prevention, in a news release. "Over the last 10 years, four children under 14 and younger died each day. We hope that by helping parents and caregivers use the right car safety seat for each and every ride, that we can better protect kids and prevent tragedies."

Best Practices Recommendations

The AAP's policy statement includes the following five recommendations for optimal safety:

1. All infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by the seat's manufacturer.
   
2. All children who have outgrown the rear-facing weight or height limit for their car safety seat should use a forward-facing car safety seat with a harness for as long as possible, up to the highest weight or height allowed by the seat's manufacturer.
   
3. All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle lap and shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age.
   
4. When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection.
   
5. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

The recommendations are presented as final steps in an algorithm included in the statement.

An accompanying technical report summarizes the evidence supporting the recommendations, as well as that for other safety-related issues, including

• proper use and installation of child restraints,
  
• exposure to air bags,
  
• the safety of children left in or around vehicles,
  
• travel in pickup trucks,
  
• travel on commercial airplanes, and
  
• child restraint laws.

The technical report also includes a list of car safety resources for health care professionals and families.

The policy statement and technical report will appear in the November print issue of Pediatrics.

Family Physician Perspective

For many parents, the family physician is one of their most trusted sources of information. And if there's one way FPs can make an immediate difference for their patients, it's in making sure that parents properly install and use car seats.

"Parents are often embarrassed that they don't know the guidance for different ages and sizes, but when I can assure them that it is complex and frequently changing as we accumulate more evidence from research, you can see their relief," Shannon Dowler, M.D., a family physician in Arden, N.C., told AAFP News. "Reassuring them that asking if they are uncertain is always OK and applies to all aspects of health care."

Dowler shared that when she was a young parent with infants nearly 20 years ago, "even with a medical degree, figuring out how to install our first car seats was a struggle." Although the design of car seats has improved greatly since then, whenever she sees patients who are having their first child, she makes it a point to talk with them about installing car seats -- even before the child is born.

"This is actually a really important prenatal conversation; ideally, that occurs in the last trimester of pregnancy," said Dowler. "More important than packing the hospital overnight bag is properly installing the child safety seat well in advance of delivering the baby.

"New parents are often overwhelmed and stressed, and installing your first car seat is pretty stressful. Doing that in advance and having it checked for proper installation will make everyone more comfortable on that first ride with a new baby."

In some cases, Dowler has taken additional steps, such as providing a demonstration or referring patients to a certified car seat installer.

"In one of my practices with a large migrant population, we had an outreach team that would do just that, especially for patients whose primary language was not English," she explained. "We found that language barriers created special risk for those families, and having someone assist with the logistics of car seat installation was a real benefit to those families."

Evidence backs up Dowler's approach to child safety. Although studies vary in their methodology and findings, often-cited research conducted by the National Transportation Safety Board shows that although 96 percent of parents and caregivers think they have installed their child's car sear correctly, about 80 percent of all car safety seats are actually used or installed incorrectly, which greatly reduces their effectiveness. The good news is that if an accident occurs, a correctly installed and used safety seat can reduce the risk of death in infants and toddlers by as much as 71 percent.

Dowler has also witnessed firsthand how car seats can save lives. As a resident, she came across a single-vehicle accident while driving home from the hospital early one morning. She didn't see any movement, "but I heard crying from the car," she remembered. She approached the car and looked inside. "On the floor, pushed almost under the front seat and upside down, an infant was restrained in what was a rear-facing car seat," she said. Of the four people in the car, the infant was the only one uninjured. At that point, she recalled, "The life-saving benefit of car seats was clear."

Because the AAP recommendations no longer use specific age limits, some parents may choose to keep children in rear-facing seats or in the back seat longer than the kids would like. Dowler's advice for handling pediatric protests?

"I would encourage them to persist!" she said. "It's tough if you have a small child who has to stay in a car seat longer than their friends -- peer pressure starts early these days. Moving to the front seat is a rite of passage for most children and teens, and who can blame them? The view is much better from the front, and you can control the radio."

That brings up another important car safety issue parents need to consider.

"There is clear evidence that the life-saving benefits of airbags for adults are not the same for children," Dowler noted. "In fact, because children's bone density is not the same as adults', the front airbags can even lead to more damage for children. So as parents, we have to make the call to keep them in the back seat."

Ultimately, Dowler recommends that family physicians talk to patients of all ages about vehicular safety. Remember, too, that the AAP's policy statement isn't aimed solely at the parents of infants, children and adolescents, but also pertains to anyone who drives with a child or infant in the car. And although she doesn't recommend any specific type of car seat, she does recommend that parents and caregivers always use one as a practical matter.

"From a resource standpoint, something is better than nothing for children at all times," she said.

More From AAFP
American Family Physician: Preventing Injuries: How Can I Keep My Child Safe?
(4/1/2013)

Additional Resources
CDC: Child Passenger Safety: Get the Facts

National Highway Traffic Safety Administration: Car Seats and Booster Seats

Safe Seats 4 Kids