Advise use of rear facing child car seats for children under 4 years old
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1994 (Published 11 June 2009) Cite this as: BMJ 2009;338:b1994
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I have to address the issue of children being harder to entertain
when rear facing. My daughter is 2.5 years old and has been rear facing
all her life. She has an excellent view out the side and back windows and
is happy to point out all the things she can see and wave to the cars
behind. I, as a driver, am less likely to turn around to engage with her.
I know that I can't see her anyway, so I don't even try. We talk instead.
If another passenger sit in the back, they can interact with her better as
they sit face to face.
I don't think that it is more "fun" to face forward in the car at all. It
is simply a case of what you are used to. New ideas are always hard to
introduce, but I think that our children will look at us with horror when
they hear about how they were not rear facing in the car. Just like we
look at our parents in horror when they tell us about how we were not even
wearing seat belts when we were little (back in the stone age).
This is a case of changing attitudes. The safety aspects speak for
themselves.
Competing interests:
None declared
Competing interests: No competing interests
I'm from the USA, and the evidence in the last few years of the
benefits of extended rear facing is overwhelming. As far as I have read,
the 12 mo / 20 lb guideline to front face a child first appeared in 1996
by AAP.
That recommendation was based on "peer-reviewed" studies, dating back
to 1986. Actually, more than half of the peer reviewed articles didn't
address rear facing, but instead dealt with premature or disadvantaged
children. Although in 2002, AAP did add quietly the statement "to rear
face as long as possible", is seems it has not been embraced by the
public. There seems to be an implied degree of safety with the 12 mo / 20
lb threshold.
I only began this research after my grandson broke his neck in a
front facing car seat. He was 18 mos / 33 lbs, more than 50% over the
threshold to front face. He did survive, and is doing remarkably well. To
view the details, visit www.joelsjourney.org
I am currently compiling rear facing studies, such as this, to press
NHTSA to revisit or revise the front facing guideline. And, there is a
mountain of evidence that supports rear facing beyond 12 mo / 20 lbs.
My thanks to all involved in this study!!
Competing interests:
None declared
Competing interests: No competing interests
I read this article with interest after a recent trip to Sweden and
hiring a car there with a child seat installed for our 3 year old -
backwards. Here in Australia all kids are spun around by 12 months.....
There is no mention I could see in the article regarding the position
of the child in the car.
In Sweden it is common practice to have the child rear-facing in the front
passenger seat with the airbag disabled.
While obviously this would resolve many peoples argument regarding
being able to 'see and entertain' the child, making it in fact easier than
a front facing child in the rear, I wonder if there is data on the safety
of child seats in this position as opposed to the back.
Any thoughts?
Competing interests:
None declared
Competing interests: No competing interests
Our son is only 7 months and is 13kg. We are going to have to spend a
lot of money in order to obtain a rear facing birth - 4 years seat. I am
very disappointed that in Scotland only 1 retailer sells a model that will
fit the bill. Never mind the overwhelming evidence that they are safer,
for the larger baby, (Our child is on the 99centile) there is NO OPTION.
Action has to be taken to force the major retailers to stock more of these
and train there staff to fit them properly.
Competing interests:
None declared
Competing interests: No competing interests
Rearfacing child seats were first proposed by the late Bertil Aldman
(Chalmers University, Sweden) in 1963. He told me that the idea had come
from looking at what the US Space programme had concluded for the
astronauts when the space capsules were taking off and landing.
Of course it is true that it is safer if the forces of acceleration on the
human body are spread over as much of it as possible and this is best
achieved over the back from buttocks to head, and this applies to adults
and to children. So all car passengers would be safer rear facing but this
is obviously more easily achieved for young children. This applies not
only to frontal impact but also side impacts with any frontal component
(most). However, as pointed out by other respondents, there are some
practical issues, such as leg room, visual communication and even muddy
shoes on upholstery!
The last time that I studied it, forward facing child seats were at least
as effective at reducing serious and fatal injuries as adult seat belts,
if not more so. It is important that rear facing child seats are
available for parental choice so that they can balance ultimate safety
verses daily convenience but also important for them to know that rear
facing is safest.
Competing interests:
None declared
Competing interests: No competing interests
Thank you for the science. Parents can make an informed choice.
What about the sociology? My wife and I have had many long journeys with
our three children in forward facing restraints on the back seat. Whoever
was in the passenger seat enjoyed relating to our children by turning
around and talking, singing, telling stories and occassionally
administering discipline. I would need compelling evidence of greatly
increased risk in order to relate to my children via mirrors.
We make choices about risk, whether in sport as in swimming or
sailing or in travelling. My children have subsequently as adults
travelled in highly risky buses in Malaysia, Peru and Tanzania whilst
working in these countries. They have scuba dived and boarded off piste.
If I had my time again I would still strap them in forwards after one
year of age risking greater injury and would still support their desire to
take risks whilst travelling for a greater advantage.
Competing interests:
I prefer to take an increased risk if I feel the subsequent benefit is worthwhile
Competing interests: No competing interests
Many parents use one of the widely available mirrors, which adjust to
any angle,
in order to be able to check on children in rear facing car seats. The
driver can
then see them in the rearview mirror, similarly to a forward facing child.
The
child can also see the driver via the reflecting mirrors, the same as a
forward
facing child.
For most parents, their only experience of rear facing car seats is
with infant
carriers (group 0+). Anecdotally, some parents comment that their child
was
'happier' when they changed to a forward facing group 1 seat. However,
this is
also reported when parents change their children to rear facing group 1
seats.
Therefore this may be due to other factors, such as the larger, less
restrictive
seat, the ability for the child to sit in a more upright position (as
opposed to
group 0+ seats) and the fact that group 1 seats are higher up, allowing
the child
a better view.
Another hypothesis regarding the safety aspect would be that as
drivers are
unable to turn around and see a rear facing child, they will be less
likely to take
their eyes off the road. Certainly no-one would want the safety benefits
of rear
facing car seats to be negated by an increased likelihood of an accident.
There is
no data concerning this at present.
Competing interests:
None declared
Competing interests: No competing interests
The authors make a compelling and important case for consideration of
the adoption of rear facing seats for infants. Personally, I think a great
barrier to change will be the potential perception of parents that
children will be more difficult to amuse on long journeys in rear facing
seats. I appreciate that the seats are designed so that the child has a
view out of the car’s windows, but their views will be to the side and
backwards rather than the driver’s man focus which is to the front. This
is a non-trivial issue as anyone who has tried to keep an infant amused
when driving will testify. Moreover it may be an important safety issue. I
would be very interested in a study that explored how the type of infant
car seat affects driver behaviour. I find is quite plausible that a rear-facing toddler may induce the driver to take their main focus away from
the road in front of them more than a forward-facing toddler would. This
might be caused by the need to share a viewpoint with the child while
engaging in conversation about the world outside the car, or because the
child is more fractious. It would be unfortunate indeed is rear-facing
seats made children safer in crashes but also increased the likelihood of
a crash occurring! Before we can push for change we need to explore
whether choice of child seat influences the probability of being in an
accident as well as the consequences of that accident. The authors make a
compelling case for half of this equation; the other half is very much in
need of investigation.
Competing interests:
None declared
Competing interests: No competing interests
I was interested by the article , thinking about the reluctance of
civil airlines to adopt the military transport style of aft -facing seats
.However ,one of my children read the BMJ cover headline "Car Seats- Which
way should they face?" and declared it a no-brainer - if the seats are
facing backwards , the driver will crash!
Competing interests:
Owner of lots of children who fight over car seat positions.
Competing interests: No competing interests
Author's response Re: front seat?
The evidence that we cited in the article (reference 9) stating that
the back
seat is safer for children comes from America and concerns children of all
ages in all restraint types, or no restraint at all. There is no direct
comparison
between children aged 0-4 properly restrained rear facing in the front
seat
versus the back seat.
There is some evidence from Sweden (reference 10 in our article) that
for the
types of rear facing restraint that rest against a structure in front of
them
(dashboard or front seat), there is a safety advantage in being on the
front
seat. This is because of the slightly softer frontal support of resting on
a
front seat compared to resting on the dashboard. However, many of the
group 1 rear facing restraints available today have support legs instead
of
leaning on a forward structure, and we are unable to find any evidence
comparing front versus back seat positioning for these.
There is also the issue of front passenger airbag de-activation.
Different
vehicles have different mechanisms for doing this (ie some have on/off
switches, some require a dealer to do it). A front passenger airbag must
never
be active when a rear facing child restraint is placed on the seat,
whereas if
an adult is sitting on the front passenger seat, then the airbag should be
switched on for their safety.
Competing interests:
None declared
Competing interests: No competing interests