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Wednesday, June 11, 2008

Post#8 A Car Seat Conundrum

Henary B, Sherwood C, Crandall J, et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007;13(6): 398-402

A 2007 study on injury prevention, cited above, shows that children ages 1-2 years of age who were placed in a forward-facing car seat had a 5.32 times greater risk for serious injury as opposed to children in a rear-facing car seat. Five times the risk. WOW.

It is common practice to keep children rear-facing until 1 year of age AND 20 lbs. However, after children turn 1, most moms can't wait to turn the car seat forward. The change in position allows greater visibility of the child, more interaction with the child (perhaps a negative in terms of accident prevention), easier access to the child (again maybe not so good for accidents), and a perception that the child will now be happier with the new and improved view of the mother and the world through the front windshield. I certainly thought our first child cried less after we turned her forward.

But this new finding indicates that the child will be safer facing the world through the rear window, as children in Sweden do until 4 years of age. In fact, the study found that for children under 12 months, the safety factor of a rear-facing car seat was only 1.79 times higher than a forward-facing car seat. Meaning, from a statistical standpoint, it is even more important to keep them rear-facing from 1-2 years of age then it is before they turn 12 months.

This data poses a conundrum: At what point does the comfort and well-being of the child/family trump a statistical safety factor?

There is no question in my mind that my first child hated her car seat for the first 12 months of her life. No, hated is too weak of a word. Loathed. My wife and I counted the days until we could turn her forward, and in fact we cheated by graduating her a few weeks shy of her first birthday. Life in our car became significantly more serene once we made the change, and driving no longer raised our blood pressure.

And though the above study clearly demonstrates we took a risk in making the switch, I could argue a significant counterpoint. I believe the harrowing cries produced by my daughter while driving posed a risk in and of themselves. The amount of anxiety that her crying generated was a driving distraction which could have (but never did) led to an accident.

Did her crying offset the potential 5X increase in risk we took by turning her forward? I'm not sure and never will be. Would I change what we did with her based on this new data? Perhaps, but probably not.

However, I do plan to keep my third child (and would have with my second child) rear-facing for as long as he (and my wife) will tolerate. Seems the boys (child #2 and #3) are more content facing the world from the rear. (I'm not sure if there are any implications here about their future!)

And like many pieces of advice available to mothers out there, each must be weighed and individually determined for each family. Not only that, depending on the demeanor of the child in his/her car seat, an individual family may use different timelines to make the switch forward for each of their children.

One thing is clear: I do believe that this information is pertinent, and pediatricians need to make it available to their patient population so that each family can make an informed decision as to what is best and ultimately safest for them.


MississippiCPST said...

I am a CPST at a non-profit. During Car Seat inspections I hear that alot. I agree the stress of a crying child adds distraction but there is no way to capture that data as it relates to the issue. I do however, hear it less with moms that ride in the back (requires two adults) or when there is child #2, 3 etc. Is it the close proximity of others that makes them calmer (or less alone) So my question is from 0-12 mos, which of the senses is used to know you are there or not there, sight sound or smell. Do you think there is a relationship?

Peter Jung said...

Wow, tough question. I doubt there is any great scientific way to answer this question, but here is my best shot. The order in which children's senses become sharp is something like this: smell and sound first, then sight. Sight is usually not very good until 2-4 months of age. That being said, soothing a child usually requires a combination of hearing, touching, and seeing the mom. I don't know that any one sense is more important than the other in this regard. Moms, even when sitting in the back next to a child, being unable to pick up their child, may be able to sing and make eye contact with a child, but short of taking them out of the car seat, often fail to soothe an agitated child. That being said, some kids will do better just by feeling their mom's hand or seeing their face. I think it is different kid to kid and really trip to trip. So really I don't have a good answer to your questions!! Bottom line is the data does not lie-which I think you agree with-but I just want to reiterate. The data in the Henary study is not about comparing the propensity to get in a crash when riding with a RFCS vs FFCS, it is about comparing how serious the injury is in crashes that have actually occurred. So, whatever the reason for the crash (the baby distracting you or not), it is clear that a child will fare much better if they are rear facing (particularly in side crashes). Sorry, I couldn't directly answer your question.

MississippiCPST said...

Thank you for your response and I agree about the data, I use the AAP Family guide to car safety seats as a reference when I talk to new moms at the hospital and was encouraged that they promote rear facing until at least 1 year AND 20lbs, but in addition say "for as long as possible". When I explain that the safety seat absorbs much of the crash force and the combination of the child being rear facing and being held down in the seat by a 5 point harness (more so in a frontal collision)seems to help them understand why it is important. A group of L&D, Post-Partum nurses are going to take the CPST class (for CME's & knowledge), and the final exercise is to conduct a child safety seat inspection check point. We'll be doing this at a pediatricians office. I think this will be one of the best we've ever done. What better place to help parents with getting those car seats properly installed? So many have trouble getting it in so it doesn't move more than an inch side to side & front to back. Maybe your local SAFE KIDS chapter could do one at your practice on well baby check day?

Anonymous said...

Dr Jung,
Question: Insect experts say to adequately repel insects (mosquitos in particular) a solution (spray or lotion) that contains 10-60% DEET is needed. What do you recommended as it pertains to age groups?

Peter Jung said...

From our Summer Newsletter at my practice:

• Do not apply mosquito repellant to infants under 2
months of age. (May use Avon’s Skin So Soft instead)
• Do not apply over cuts or wounds.
• Do not apply to young children’s hands or near eyes/
• Do not apply under clothing.
• Whenever possible, dress children in light colored
clothing that covers both arms and legs.
• Avoid over application. Use just enough to cover
exposed skin and clothing.
• For application to child’s face, apply to adult hand and
then rub on face.
• Repellant containing DEET (10-30% concentration) is
safe for use on infants.
• 10% DEET is effective for up to 2 hours of protection.
• 30% DEET is effective for up to 6 hours of protection.
• Picardin is an effective synthetic alternative that
provides protection for up to 2 hours.
• Oil of Lemon of Eucalyptus is an effective plant based
insect repellant that provides protection for up to 90
• Mosquito netting (treated with permethrin or
deltamethrin) over bedding, strollers, and car seats also
provides protection.
• After returning indoors, wash treated skin with soap
and water.

Hope that helps!

Miranda Heart said...

I think I'm catching on a little late here. But, I've seen parents parent from the front seat ALOT. You stated it yourself. The 5X more likely to be injured I'm sure has more to do with the parent being distracted more and getting into an accident more so than the fact that the child is facing forward. Think of it. Driving 40mph and cooing to your cute little 12 mo old and you slam into the car in front of you because you weren't paying attention is going to cause way more damage than paying attention to the road and hitting a car in front of you at 15 mph. There just seems to be too many variables.

My daughter was always big for her age. As soon as she hit 20 lbs we turned her around. I do quite a few things that would probably get me ticketed, but I noticed immediatly that I was less distracted emotionally, but my attention was more on her. I won't go into how bad it's been, but there have been moments when I had to really shake myself for being so rediculous. I think we should put more emphasis on practicing safe driving and less on which direction our children face.

And I really hope this post didn't come across as angry. I just wonder sometimes what these statistics are based on and how often human behavoir is factored into it.

Peter Jung said...

Mrs. Heart,

You bring up some excellent points. No question the human element cannot be captured in the data effectively. However, this study was not analyzing the likelihood of getting into a car accident. In other words, the data is not saying that you are 5X more likely to get in a serious accident if your child is forward facing vs. rear facing. What the data compares is, once an accident has occurred, what are the odds that your child will have severe injury as a result of the accident. The accident severity was factored into the study such that RFCS in severe accidents were compared with FFCS in severe accidents (and minor RFCS accidents were compared with minor FFCS accidents). Even the position of the child in relation to the point of impact was accounted for. Once all the variables were accounted for to level the field in terms of data analysis, the children (1-2 yrs of age) in a RFCS were 5X less likely to have a severe injury compared to children in a FFCS. In general it is thought that the RFCS is safer than the FFCS because it distributes the impact of the accident over the entire body (in particular giving the head more support and protection), whereas the FFCS focuses most of the crash forces at the belt points.

However, even given this data and detail, each family will need to decide what is best and safest for them.

Hope that explains the data a little better!

Dr. Jung

Lilli said...

This is great info to know.

Darren Blair said...

Great post! Thanks for the information.