Rear-Facing is Safest
Rear-facing provides a superb way to travel for infants and toddlers. Statistically, it reduces the risk of death by 71%. In an article1 published in Injury Prevention in December 2007, lead author Basem Y. Henary et al found that forward-facing children under the age of 2, especially those in side impacts, were 75% more likely to be injured. Why? It's because of the way the rear-facing carseat protects a child. It cradles the head, neck, and back.
The most common type of crash is the frontal crash. In a frontal crash, the entire back of a rear-facing carseat absorbs crash forces, protecting the child's head, neck, and spine. In the less common, but more injurious side impact crash, the rear-facing carseat again protects the head, neck and back. Since there's almost always an element of forward motion in a side impact—such as when a vehicle is going straight through an intersection when it's struck in the side by a red-light runner—a rear-facing seat does a better job of keeping a child's head contained within the safety of the seat.
What about an older rear-facing child's legs—won't they be broken by the back seat? Maybe, but it's unlikely. Again, statistically, the most common type of crash is the frontal crash. Physics tells us that everything will keep moving toward the point of impact, including the child's legs which will fly up. Broken legs are much easier to treat than a broken neck, which is a real risk if a child is turned forward before the neck bones have hardened and the ligaments have developed enough to withstand crash forces. Another recent study2 tells us that the legs are more likely to receive serious injuries in crashes when a child is forward-facing, most likely from the child's legs impacting the front seatbacks.
The professional association that most pediatricians belong to, the American Academy of Pediatrics3, has recommended since 2002 that children remain rear-facing for safest protection in vehicles. Unfortunately, because many pediatricians are busy with day-to-day appointments and running their businesses, child passenger safety rests on the back burner and they are unaware of the recommended guidelines of their own association. If this is the case with your pediatrician, please print the guidelines and take a copy to his/her office. The guidelines changed in March 2011, so word-of-mouth is very important to let our health providers know about the changes. The AAP also has a web page designed for parents called Car Safety Seats: Information for Families 2011 At the same time, the National Highway Traffic Safety Administration (NHTSA)4, changed its guidelines to reflect a longer rear-facing and harnessing timeline. NHTSA's guidelines state that a child should remain rear-facing for as long as possible, until the child reaches the top weight and height limit of the rear-facing carseat, or from brith to around age 3.
How long should a child stay rear-facing? Until the s/he reaches the rear-facing limits of a convertible car seat. The weight limits vary by manufacturer, so be sure to check the label on the side of the seat or the instruction manual. When you buy a convertible seat, look for a seat with a high rear-facing weight limit. All carseats have height limits stated on the label and some manufacturers are quite adamant that they be followed. The general rule is that there be at least 1" of carseat shell above the child's head to allow for complete head protection in a crash. Height limits are difficult to reference because two children may be exactly the same height, yet fit differently in the same seat because one child carries his height in his legs while the other carries his height in his torso. A child who is tall in the torso will outgrow a harnessed seat faster than one who is taller in the legs. It is up to the parents to make the tough decision on how to follow the height guidelines given for the carseat. Parents must weigh the advantages of rear-facing with how far the child's head is below the top of the seat and make the decision.
1Henary, B., et al. "Car Safety Seats for Children: Rear Facing for Best Protection." Injury Prevention 13 (2007): 398-402.
2Jermakian, J.S., et al. "Lower Extremity Injuries in Children Seated in Forward Facing Child Restraint Systems." Traffic Injury Prevention 8 (2007): 171-179.
3Durbin, D., et al. "Policy Statement—Child Passenger Safety." Pediatrics 127 (2011): 788-793