Rear-Facing or Forward-Facing–What To Do and When To Do It

In the three years between when I had my first born to second born, a lot had changed. New strollers, joggers with front swivel wheels, a whole new array of toddler snacks, and one of the most important things–recommendations on car seats. When my son turned one, I was so excited to have him face forward that I switched the car seat around on the day of his first birthday. Then, I had my daughter and I was hearing that parents should wait to turn them from rear-facing to forward-facing. But wait for what? A certain age? A weight milestone? Breezy Mama turned to Pediatrician Dr. Jon Conti for some answers. –Alex

Four years ago, the thing to do was to turn your child from rear-facing to forward-facing on their first birthday–this is no longer so? What is the new recommendation?
Although the official recommendation remains (once a child is 1 year old AND at least 20 pounds they may be turned around), compelling new data is emerging.  In April 2009, the official news magazine of the American Academy of Pediatrics (AAP) declared that rear-facing car seats are safer for children.  The article cited that toddlers between the ages of 12 & 23 months who ride rear facing are 5 times safer and 75% less likely to experience serious injury or die than their forward-facing peers.  More telling perhaps is the 2005 Swedish study detailing 17 years of accident data showing that the highest injury-reducing effect was found in rearward-facing child restraints up to 4 years of age.  That’s correct: 4 years of age, not 1 year of age!

Why?  Car seats are designed to absorb forces and spread these forces across a larger area of the body (the entire back, ribs, neck and head), putting less stress on any one part of the body.  For adults, seat belts distribute deceleration and impact forces to the strongest parts of the body: the hips and shoulders.  Infants, on the other hand, don’t have many body parts that are strong enough to withstand crash forces. Additionally, small children have proportionately larger heads and weaker neck muscles than older children and adults.

Therefore, during an accident, rear-facing seats can distribute the force of a rapid deceleration/crash more evenly to the strongest parts of their small bodies while more likely supporting the head and neck.  Perhaps a video at this point will drive the point home. . .

The take home message:  turning a child’s car seat around to the facing forward position may actually be a step backwards. So what’s the hurry?

If the child is rear-facing because they do not meet the weight requirement to turn around, but they are tall and their legs are scrunched against the back seat, is this a concern?
According to the AAP, a child should be fit to a car seat so that their heads are within an inch of the top of the seat.  However many parents worry that if the child is rear-facing, their feet will touch the seat back, resulting in broken legs in a crash.  Yet if a crash is severe enough to break a rear-facing toddler’s legs, then there would also be enough forward force to cause severe neck injuries for a forward-facing toddler.  While it’s dreadful to hypothetically choose between injuries, the chance of full recovery is greater for broken legs than broken necks.

Similarly many parents also comment that their child appears cramped when rear-facing.  Regardless of the direction, some children never like sitting in a car seat, and they may cry.  Although it is easy to turn the toddler around to keep him or her happy, you are choosing fussing over potentially severe head, neck and spine injuries.  Being properly restrained makes it more likely that a baby or toddler will survive a crash to cry another day.

Which car seat brands can support a heavier child facing rear?
The good news is that many new convertible car seats have a rear-facing weight limit of 35 pounds.  For those of you who already have one, check your car seat’s instruction booklet for its rear-facing weight limit, and under no circumstances exceed this limit.

For those of you in the market for a toddler car seat, at present there are three car seats that accommodate children up to 40 lbs rear-facing:
Graco My Ride 65 Car Seat (For Amazon’s price of $149.99, click here to order.)
Safety 1st Complete Air (For Amazon’s price of $167.26, click here to order.)
Sunshine Kids Radian (For Amazon’s price of $225.54, click here to order.)

Periodically check car seat makers websites for updates.

I believe a child can legally be in a booster seat when they weigh 35 pounds–what would you recommend?
Presently the law is that children may transfer to a booster seat when they are over 40 lbs.  This is because a toddler’s pelvic bones are not fully developed and cannot withstand such great forces.  A booster seat raises the child so that the lap part of the seat belt can be positioned low and tight across the thighs, to prevent abdominal injury.  Further the booster seat makes it possible that the shoulder belt crosses at the collar bone and center of the chest, not across the neck.  Until it’s time for the booster seat, remaining rear-facing maybe the safest way go.

When the child is big enough to be facing forward, how long should they stay in a seat with a 5 point harness?
When they can properly fit in a booster seat.

My son is always asking me when he can sit in the front seat–obviously, since he’s 4, this is a long way off. What is the legal weight limit to sit in the front? Or in the back without any kind of seat?
For everyone, in almost any frontal crash, the rear seats are the safest in the car.  In fact, the NHTSA recommends that ALL children 12-years-old and under should be in the back seat.  And according to California state law, all children under 6 years old AND under 60 pounds MUST be properly restrained in an appropriate child passenger restraint system (car safety or booster seat) in the rear of a motor vehicle.

If you are tempted to put your toddler or young child in the front seat, consider this: deployment of front air bags standard in all new cars can be very dangerous to toddlers–particularly those riding in rear-facing car safety seats–as well as those young school-aged children not properly restrained.  Even in a relatively low-speed crash, the air bag can inflate, strike the car safety seat, and cause serious brain and neck injury and death.

If you have no choice but to put your infant or small child in the front seat, check the vehicle owner’s manual to see if the air bag can be turned off.

Do you know of any common mistakes when installing car seats?
There are plenty of them, and they vary among your chosen car seat and the automobile that it is placed in. Thus, it is highly recommended to have a professional check your car seat installation.  If you have questions or need help installing your car safety seat, find a certified CPS Technician.  Lists of certified CPS Technicians and Child Seat Fitting Stations are available on the NHTSA Web site or at www.seatcheck.org, or by calling the NHTSA Vehicle Safety Hotline at 888/327-4236 or Seat Check at 1-866-SEATCHECK. Here in California, the CHP as well as the county sheriff provide this service free of charge.

There are “services” that come and install your car seat correctly. Is it really worth it to hire these people?  It seems so easy to do yourself. . .
Why pay for something that you can have the police do for free?

Anything you’d like to add?
The bottom line:  based on new studies, experts say that children are safer if they remain in a rear-facing car seat well beyond a year of life, up till 4 years old!  Thanks to higher rear-facing weight limits on newer car seats, nearly all toddlers should remain rear-facing until they reach 40 lbs. (or the weight & height limits of your car seat).  The safety advantages far outweigh any inconvenience.

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About Jon Robert Conti, MD FAAP: Dr. Conti earned both a BA in Psychology and a BS in Biological Sciences from the University of California, Irvine. He went to medical school in Michigan, and completed his pediatric residency from the Children’s Hospital of Los Angeles in 2001—consistently ranked by US News-‘Nation’s Best Hospitals’ since the 1990’s. Dr. Conti is Board Certified in Pediatrics & Adolescent Medicine and presently cares for patients & their families at Sea View Pediatrics in Laguna Hills & San Clemente. He can be reached for consultation at Sea View Pediatrics: (949) 951-KIDS (5437)