Babies and toddlers should ride facing backward.

That’s the simple message coming from car safety experts these days, who say the common practice of turning babies around at their first birthday is dangerous.

For years, the guidelines have stipulated that children need to be at least 20 pounds and 1 year old before they are turned from a backward- to forward-facing position in their car seats. Parents and physicians often took that to mean that children were safe facing forward once they passed those benchmarks. State laws followed suit; Oregon law mirrors those recommendations.

New research, however, shows children are much safer riding facing backward until at least age 2, and some experts say the longer the better.

“There’s no question that orientation is better for kids,” said Dr. Dennis Durbin, a national expert on child safety and a pediatric emergency physician at the Children’s Hospital of Philadelphia. “There’s nothing magic that happens on a kid’s first birthday that renders them now safe forward-facing.”

Though the evidence is unequivocal and has been out for several years, it has taken awhile to catch on. Pediatricians still sometimes tell parents they are safe turning kids around after their first birthday, and the American Academy of Pediatrics, whose guidelines often set the standard for practice across the country, still has the 20-pounds/1-year recommendation. This year, a committee is working on revising those recommendations.

Until last summer when she read a news bulletin, Dr. Wendy Sue Swanson, a pediatrician at Seattle Children’s Hospital, used to counsel parents that it was OK to turn kids around when they reached their first birthday. “The word’s not really out yet,” she said.

‘A no-brainer’

The strongest data for keeping kids facing the rear come from a 2007 study in which researchers looked at 15 years’ worth of information from crashes involving children younger than 2. They found that, overall, children were much safer in a rear-facing car seat than a forward-facing one. The data showed that, in a crash, a child in a rear-facing car seat was 75 percent less likely to be seriously injured regardless of the type of crash. But the real shocker came when the researchers narrowed the numbers to look only at children between the ages of 1 and 2. In this group, the kids in rear-facing seats were five times less likely to be seriously injured in a crash.

Once you look at that data, said Swanson, “it’s a no-brainer.”

Other studies from Europe bolster the case. Children there, experts said, sometimes sit facing the rear until they are 4 years old. “Their crash data is tremendously different than ours,” said Dr. Joseph O’Neil, a child-injury expert and an associate professor of pediatrics at Indiana University. “They don’t see the injuries that we do.”

The reason that young children are so much safer in rear-facing seats has to do with their head and neck structure. “A young infant’s head is much larger than the rest of their body relative to an adult,” said Durbin. In a sudden stop, such as a crash, that can make the head whip forward.

Durbin said there are other structural differences as well. Young children have weaker neck muscles than older children and adults. Their ligaments are looser. And the bones in the neck aren’t locked together in the same way as an adult’s; the bones, therefore, are more prone to slide over each other. “All of these features,” Durbin said, “place the baby at a greater risk of spine injury.”

Durbin said riding facing forward puts children at risk of traumatic brain injury, paralysis or even death. A significant injury to the spinal cord, particularly in the upper neck where it meets the brain, can be fatal.

When the child is facing backward, the car seat prevents the child from flying forward and supports a child’s back and neck better. “The neat thing about rear-facing seats,” said O’Neil, “is they kind of cocoon around the child to protect them.”

O’Neil and Durbin are both on a committee that will be revising the AAP guidelines. Durbin, the lead author, said he hopes to have them out by the end of the year.

Durbin stopped short of saying the new guidelines would dump the 20-pounds/1-year language, though he did say it would try to change the emphasis. “These aren’t going to be some sort of easy-to-remember numbers,” he said.

The guidelines, Durbin said, will also try to clear up ambiguity in the current recommendation. The pediatric academy and the National Highway Traffic Safety Administration guidelines both tell parents to turn their children around when they are at least 1 year and 20 pounds. They do not give any guidance as to how far past these benchmarks a child should be before they are flipped.

What to do

Until the new guidelines are in place, what should parents do?

Physicians say the best thing is to buy a convertible car seat and keep children facing the rear until they reach the height and weight limit of those seats.

Many parents start with an infant car seat, said Dr. Michelle Mills, a pediatrician at Bend Memorial Clinic. These seats often have detachable bases so they can be easily removed from the car. Parents can tote the infant in the same carrier through walks and errands without switching from one seat to another.

Infant car seats typically hold infants up to 22 pounds, though there are some that go to 30 pounds or more.

Once a child gets to the weight limit of the infant car seat, Mills said, she counsels families to buy a convertible seat.

Convertible seats can face backward or forward. Typically, the seat will have a separate and lower weight and height limit in the rear-facing position, often about 35 pounds and within an inch of the top of the seat. After the child reaches those limits, but not until then, Mills said, parents should turn the seat around.

Mills said most children will reach the height and weight limits of the rear-facing convertible seat at about age 2.

Parents can also start out with a convertible seat, which will safely hold a baby that weighs at least 5 pounds. These seats, however, are not as easily removed from the car and are not meant to be used outside of the car to carry the baby.

Parents who have a separate stroller and carrying system for the baby might want to think about using a convertible seat from birth, said Mills.

Some parents have been resistant to the new recommendations, Mills said, especially those who have already turned their child around. “Kids tend to like facing forward, they like the interaction.” She suggested, if the child has an older sibling, having that child help entertain the youngster.

Swanson said she also hears protests from parents. Often, she said, when parents say their child will not like riding backward, it is, in fact, the parents who are resistant. She suggests mounting a mirror on the back of the rear seat so that parent and child can see each other. For especially hesitant parents, she asks them to try it for a week. “No one have I had come back in the clinic and say it didn’t work.”

For parents who have already turned their child around and may be flipping them back to facing backward, she suggested talking with the child. “If you provide a great explanation and you frame it in a positive light, they just make the adaptation”

Another objection from many parents is that a larger child’s legs will hit the seat. The concern is that children could hurt their legs in an accident.

There is no data that show kids are more likely to hurt their legs in an accident when facing the rear, said Swanson. Even if it were true, she said, “we would always rather treat a fracture of a leg than a fracture of a neck or a head injury.”

Cultural shift

There are challenges with the new advice. New car seats are expensive. The Britax convertible seat, one of the most popular, costs $300 and up for seats with higher weight limits.

For low-income families, there is help through a state program (see “Resources” box above), but for any family, buying a new car seat can add significantly to expenses. Oregon’s Transportation Safety division cites the affordability of child-restraint systems as one of the primary barriers to their use.

Perhaps the bigger challenge, however, is changing the mind-set. Parents have seen turning the car seat as a rite of passage. Pediatricians, too, have long advised that meeting the 20-pounds/1-year benchmark is license to flip kids around.

“We have to culturally change the context in which we are riding with our kids,” said Swanson. Sure, we can’t give them high-fives as soon, or watch their faces light up when they recognize a doggy out the window. But with the huge safety trade-off, it makes sense to delay these joys, she said.

O’Neil said that even physicians need to change their attitudes. “What we’re trying to do now is really work with pediatricians on changing the message,” said O’Neil. “We gotta change the culture. We gotta change the norm.”

Car seat choices and options

All car seats photographed and sold at Baby Phases in Bend

Infant seats

These infant seats the Chicco KeyFit 30, the Britax Chaperone and the Graco SnugRide 35, have higher weight limits than many infant seats, which carry children up to 22 pounds. Infant seats offer the convenience of a removable base, allowing parents to tote babies on errands without removing them from their seat.

Convertible seats

These convertible car seats the Britax Boulevard CS, Britax Advocate CS and the Recaro Singo G2, allow babies to face backward until they are 35 pounds. Others go as high as 45 pounds. Once babies reach that weight, the car seats flip to allow babies to ride facing forward until between 65 and 70 pounds.

Forward-facing seats

These seats, from left, the Graco Nautilus, Recaro Vivo and Britax Frontier, allow children to ride facing forward. Though the minimum weight limits for these seats begin at 20 pounds, experts say children should ride facing the rear until they weigh more than that.

Resources

Alliance for Community Traffic Safety (www.actsoregon.org): Includes information about Oregon laws as well as best-practice recommendations.

American Academy of Pediatrics (www.healthy children.org): Includes a list of individual car seats, weight specifications and cost.

Child Safety Seat Resource Center (800-772-1315): Call for information about programs to help families afford new car seats.

National Highway Traffic Safety Administration (www.nhtsa.gov/): Includes a Web site with ease-of-use car seat ratings for individual brands.