My next book is going to be about what happens when bad data informs health policy. rear-facing car seats and booster seats are going to have a whole chapter. In fact, this issue was really the catalyst for me. Going through a major car crash made me wonder about our current car seat laws/beliefs, especially since I was taking Research Methods for my Master of Public Health degree at the time. So here is a brief summary of what I found:
Forward facing vs. rear facing- Wow. The level of zeal over rear facing car seats reaches a level of near religiosity. How did it start?
In 2007 the Henary, Sherwood, Crandall, et.al. study was published in the Journal of Injury Prevention. It analyzed data from the US National Highway Traffic Safety Administration vehicle crash database for the years 1988–2003 for children ages 0-23 months. The results of this study found that children in forward facing car seats were significantly more likely to be seriously injured in a car crash than children in rear facing car seats.
The world of children’s health and safety exploded with rear-facing zeal.
From KidsSittingSafe.com: “The data relating to the type and location of child car seat are also striking. The car seat statistics on rear-facing car seats backup the latest recommendations of the American Academy of Pediatrics (AAP) that kids should remain in rear-facing car seats until at least the age of two.” https://kidsittingsafe.com/car-seat-statistics-compilation/
From CarSeatsfortheLittles.com: “Rear facing is not a choice to be made based on parenting style or opinion; it’s one based on scientific fact. The more we know about physics and physiology, the better we’re able to protect our kids from severe injury as a result of a crash.”
https://csftl.org/why-rear-facing-the-science-junkies-guide/
From the Car seat Lady: “It’s not a coincidence that flight attendants sit rear facing. Rear facing is the safest way for everyone to travel, not just babies. Therefore it is our recommendation that children ride rear-facing until at least age 2– and ideally longer, until reaching the maximum height or weight for rear-facing in their convertible car seat, which for most kids is 2-4 years old.”
http://thecarseatlady.com/5-times-safer/
From SafeRide4Kids.com: So it baffles me when parents want to turn their children forward facing earlier than necessary. I’ve spoken to a lot of parents who treat a first birthday as some sort of graduation to forward facing. Many other parents begin to get concerned about possible leg injuries because the child’s legs are folded. Other parents simply are under the impression that their child must be uncomfortable.
Why is this? Because the parent would be uncomfortable sitting criss-cross applesauce? Personally, I like sitting criss-cross applesauce and could definitely sleep better in the car leaning back with sides upon which to lean my head. Do they make a rear-facing adult passenger seat? It’s coming, I know it, because it’s soooo much SAFER for everyone!”
https://saferide4kids.com/blog/keep-rear-facing-as-long-as-possible/
Awfully high praise for a practice that has no grounding in sound data.
Yep.
In February of 2018 the 2007 Henary, Sherwood, Crandall, et.al. study was retracted because the findings could not be replicated.
This study formed the basis for the rear-facing car seat policy that has been accepted as fact. In order for something accepted as scientifically based, if has to be replicable. If the results can’t be replicated, it can’t be classified as science. If the results can’t be replicated it’s a fluke or bad research.
Sweden’s rear-facing until 4 laws are often cited as another proof that rear-facing is safer than forward-facing, but this is what we in the research world call confounding. Sweden just has the lowest rates of traffic related fatalities in the world— across all age groups. Sweden has built roads and pedestrian crossings to be safer and is aggressive about enforcing drunk driving. They also have lower speed limits in urban areas. So there are a multitude of factors that are behind Sweden’s low rates of traffic fatalities for adults and children. You could only attribute Sweden’s low rate of child traffic fatalities to rear-facing car seats if all other factors were the same when comparing Sweden to other countries. Since there are other factors that are at play in Sweden, Sweden’s use of rear-facing car-seats until age 4 can not be used as proof that rear-facing car-seats are safer than forward-facing. In fact, according to the National Highway and Traffic Safety Administration in 2016 6% Of infants under the age of 1 who died in a car crash were forward facing while 21% were rear facing. (In 2015, those numbers for fatalities for children under 1 were 6% forward-facing and 33% we’re rear-facing.) If rear facing car seats alone were really responsible for Sweden’s low rates of infant traffic mortality, then the rear facing car seat mandate should have resulted in similarly low rates in the US. But it hasn’t.
Now, this is where the double standard of research in the classroom vs. policy in the real world. I’ve taken classes for my MPH in public health policy, research methods and program planning. If I had come to any of my professors and said I wanted to do a research proposal or public health program using a study that can’t be replicated and a case study with confounded data, I would have gotten the research smack down. My professors would have told me I need to select a different topic or do more research. But in the real world where public health can be a matter of life and death, we’re often quick to jump on unsubstantiated research if it seems to hold the promise of solving a problem or saving lives.
Now there’s no conclusive evidence yet that placing your child rear-facing is harmful. (The stats from the NHTSA for 2015 and 2016 aren’t specific enough to account for all variables and only cover two years.) But the data is pretty clear that it won’t provide better protection than forward-facing.
Booster seats
The longer you keep a child in a booster seat, the better right? After all, the American Academy of Pediatrics says that kids should be in a booster seat until 8-12 years. So here’s the deal behind the research that informed this policy. Some of it came from telephone surveys— which are informative but may be more limited than data from sources like the NHTSA. Another weakness is that much of the data comes from 1998 to 2003 when booster seats were not as widely used. This means that the sample sizes would have been much smaller, so I can’t tell us as much about what it means to have all children in booster seats. Fun fact: the CDC is still using this data and has not addressed any of the newer findings about booster seats. A 2013 study that compares larger data sets found that children in booster seats had an equal level of overall risk for injury when compared with children restrained with only a seat belt, however children in a booster were more likely to receive non-fatal injuries to the neck and chest than children who were restrained with only a seat belt. Seatbelts and booster seats were equally effective at preventing death. More research is needed to find out if this can be improved with proper usage of booster seats or if there is still no improvement.
Ok, so what can I do to protect my child?!
Buckle your kid up according to the law and don’t drive intoxicated. 35% of all child traffic fatalities were in unrestrained children. Between 2001 and 2010, 1 in 5 child traffic fatalities (<15 years old, passengers) involved drunk driving. 65% of those were children in the car with a drunk driver.
Even with all the new safety measures mandated, the United States has some of the highest traffic fatality rates of any nation in the developed world. Sweden is particularly aggressive at preventing traffic fatalities and sees them as 100% preventable not as inevitable or “accidental”. America has not adopted that approach. Traffic fatalities are on the rise here in the US- including among children ages 0-8. According to the lore of paramedics and the Insurance Institute for Highway Safety, in a crash the bigger car will generally come out ahead, so driving a SUV might give you more protection in a crash, though that’s not practical for everyone.
We were all buckled up according to the laws of the state we were driving in, though some people definitely take more extreme measures. The front of our SUV took the brunt of the crash and the air bags deployed, so it’s a good thing the kids were in the back. Even with all the new gadgets and harnesses being touted on the market and the fervor over rear-facing preschoolers and booster seats for tweens, your best bet is still to make sure your child is adequately restrained in a good car seat. Watch the straps, make sure they are tight enough and the seat is latched in properly.
Sources:
https://www.cdc.gov/motorvehiclesafety/child_passenger_safety/cps-factsheet.html
https://crashstats.nhtsa.dot.gov/Api/Public/Publication/812491
https://www.edmunds.com/car-safety/are-smaller-cars-as-safe-as-large-cars.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798005/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103211/#!po=42.0455
https://www.economist.com/blogs/economist-explains/2014/02/economist-explains-16
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598309/#!po=80.8824
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103211/#!po=42.0455
https://crashstats.nhtsa.dot.gov/Api/Public/Publication/812383
