Wednesday, January 5, 2011

Rearfacing Squishes Their Legs! And When to Forward Face

You've heard it around town, er, Facebook. Continuing to rearface past the bare minimum of one year is safest.

 But when should you turn that toddler around? When their legs are squished?

The current recommendations are to turn the child around when she maxes out the height and weight limits on the seat. In other words, there isn't a best time to do it, but due to the limits of the seat, you have to eventually do it.

The AAP says children should remain rearfacing until at least age 2 and preferably to the maximum height and weight limits of the seat. BUT PLEASE PUT YOUR THINKING CAP ON! They specify age 2 because that is the current data they have available. The study they reference compared 1 year olds and 2 year olds in car accidents and found rearfacing to age 2 was 500% safer. (Yeah, not a typo!) Here is the AAP's statement: 

This article provides an image to help you compare ages and stages of development. It's a great image to bookmark and share with others when trying to explain why rearfacing is vitally important to young children:

A common reason for parents to want to turn their children forward facing prematurely is due to leg room. It should be pointed out that forward facing a child will NOT protect his legs in an accident. In fact, leg injuries are one of the most commonly reported injuries for forward facing children. The force from being slammed forward against the harness can break their hips and pelvis and dislocate joints. Especially if the seat is installed incorrectly or if the child's harness is loose (or the chest clip NOT up on the chest) the child can slam into the seat in front of him, breaking his spine, arms, legs, etc.

And parents need to remember that if the accident is strong enough to break a leg, it's strong enough to break a spine, which is much more delicate and harder to repair. As I have quipped before:

Broken leg, cast it. Broken neck, casket. 

The reality is that as children get older, they do need to fold their legs, splay them to the side or rest them along the back seat. Before thinking this is uncomfortable, consider how children naturally want to sit. When they sit at the dinner table or drop down to the ground to play, do they dangle their legs or try to kneel on them, turn them to the side, applsauce them etc? Most people, especially children, dislike dangling their legs. Rearfacing provides leg support and comfort as opposed to forward facing, where the child is forced to move the pelvis forward and downwards while the legs dangle uncomfortably.

If you view this crash test video, you will get a visual idea of the risk of forward facing. Note that the legs make an impact first, which is where the injury occurs. The spinal injuries occur when the child moves forward and has the neck and head thrown forward.
http://www.youtube.com/watch?v=NMFPSStXfqE

Even if rearfacing had common leg injuries like forward facing, the ability to prevent extremely serious and typically fatal injuries to the spine and head would override the potential injury to the legs. This grandpa shares the story of his grandchild Joel, 18 months old:
http://www.youtube.com/watch?v=Q8gU9zzCGA8&feature=related

I have seen children rearfacing to 5 years of age and their legs are not "mashed up." I can't imagine a child properly harnessed receiving a head injury from hitting the knees...unless for some reason the child was unsafely putting her knees straight up in front of her...which would be difficult and uncomfortable to do when properly harnessed.

This video shows children of all ages rearfacing for a better idea of how the feet can be positioned:
http://www.youtube.com/watch?v=ZWKm7SenDHU&feature=related

This study in the British Medical Journal reviewed car accidents:

"A retrospective cohort study involving 870 children aged under 2 years analysed the protection offered by rear facing compared with forward facing child restraints.3 It concluded that rear facing seats were more effective than forward facing seats in protecting children aged 0-23 months for all crash types (odds ratio 1.76, 95% confidence interval 1.40 to 2.20) (box). "
http://www.bmj.com/cgi/content/full/338/jun11_2/b1994

BUT ALL THAT BEING SAID....you can also choose a carseat with the leg issue in mind. Some seats provide more leg room than others, based on how far back the seat sits from the vehicle seat. For example, my daughter in a rearfacing Britax Roundabout puts her legs on either side due to a shallow seat. But in the TrueFit, she has much more room and can cross them, bend them or set them on the vehicle seat:

(Please excuse the projectile item in this photo!)
The important thing to remember is to try a variety of seats out. Bring your child along and spend time shopping. Install seats into your vehicle to see how they fit. Find one that is safe and comfortable. You have many to choose from, that's for sure!

When is it safe to forward face? What about extended harnessing in a forward seat?

It is true that as time goes on, their bone development reaches a safer stage of ossification and their head becomes more proportionate to their bodies, reducing the risk to their brains and spinal cords. This milestone is generally around age 4. With various seats such as the Clek Foonf and Diono RXT going to 50lbs and 45lbs, there's a good chance the typical child can rearface until at least age 4 or longer.

The next stage after full rearfacing is a 5pt harnessed seat, not a basic booster that uses the vehicle belt. Most laws list the bare minimum of age 4 AND 40lbs to use a booster seat, but besides not fitting the seat well, the other concern is that many 4 year olds lack the maturity to sit upright, keep the vehicle belt in the right spot and stay that way the entire car ride. If your child is prone to unbuckling, repositioning the belt (such as moving the belt behind her or pulling it down) or falling asleep, leaning forward, sliding down, etc then a 5pt harness with intermittent practice periods in a regular booster is wise.

A 5pt harness seat does seem safer and more secure, but it's important to note that we don't have good studies showing it is safer. Many people think of race car drivers, who use an H harness. But remember that they also use a head stabilizing device called HANS. An older, especially heavier child in a 5pt harness without head stabilization might experience increased pressure on the head in a collision and this might be more damaging than using a vehicle belt with a booster.

The benefits of extended harnessing appear to apply to petite, light or otherwise small children and children lacking maturity or with special needs. Your economical choice to bridge the gap is a combination forward seat, such as the Britax Frontier or Graco Nautilus. These seats provide a harnessing option but also turn into a classic booster seat so you can use the method that's best for your child at any given time.

5 comments:

  1. My daughter rear faced for two and half years, would have done it longer but there was some car complications. Anyhow, regarding the legs, she's been forward facing for six months and still prefers to sit with her legs crossed as she did while she was rear facing.

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  2. My son is almost 3 and I've been debating about turing him forward facing. No real reason except for the fact that the goal was 2 years and we have well exceeded that. This was a timely post for me and I will keep him RFing since he is safe, happy and comfy :)

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  3. Surprised to read they recommend 40 pounds in other countries. I think i need to turn my boy back around!

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  4. What about when they start to compare themselves to their peers? My 5 yo is FF in a Britax Frontier and I have no intention of moving her to a booster but she mentions a lot that her friends are in boosters. My 3 1/2 yo is RF in a Marathon and I imagine I've got a few years before he complains and he has a while til he hits the 33 lb mark (only 27 right now) so he's easily RF until kindergarten. When is not as important to RF? I mean, when do they even each other out? Does that make sense? And likewise, when is just as safe for my older one to ride in a booster as a 5 pt harness? She's 45 lbs, 45 in tall. TIA

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  5. Great post. To respond to Maria, my kids (7 and 5) are the only children they know still in harnessed seats (it's very uncommon here in the UK). We've occasionally had comments from other kids about them being in "baby seats" but they are armed with the facts and calmly explain that our seats are much safer than boosters and so they prefer to ride in them. If pressed, they will explain all about tethering and head excursion... that usually silences the opposition! I think if kids understand why and feel like they are part of the team that has made the decision, they are much more confident about it. We're at the point now where we have to rotate the four kids I regularly transport between the two harnessed seats and two boosters, as they all want to have a go in the "safe seats".

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