Luke Voytas is a pediatrician and author in Portland, Oregon. His posts combine research and common sense to help parents be calm and confident in raising their kids.

Car Seats and Boosters and Front Seats, Oh My!

Car Seats and Boosters and Front Seats, Oh My!

To be clear, I hate talking about car safety. I have to do it multiple times a day, and it bores me to tears. I also can't deny that I have fond memories of somersaulting around in the station wagon at age 5. But it’s important - and there’s confusion, random guideline changes, and strong feelings - so I’m going to try to pin it down once and for all. Or at least until it changes next year. Let’s see what research is available and try to be reasonable about it.

The Skinny on Infant Carriers

Everyone knows their newborn should go in a rear-facing car seat, but let’s talk about seat selection. You would never skimp on your kid’s safety, and a lot of parents proudly tell me they got the most expensive seat at the store for their baby. But all car seats meet strict National Highway Traffic Safety Administration (NHTSA) guidelines, and safety rankings are only based on ease of use and clarity of instructions. Cupholders, hand-stitched leather, and shiatsu massage don’t make it more safe. So don’t hesitate to buy a cheap one. Only consider a used seat if it’s coming from friends or families who you trust.

Here’s another tip. Infant car seats generally come in two sizes, up to 22 pounds and up to 30/35 pounds. Now a lot of savvy parents pay a little extra to get the bigger seat, thinking they’ll be able to use it longer. But don’t do it! By the time your kid is 9-12 months (probably around 20 pounds), your days of lifting that carrier into and out of the car will be long gone and you’ll be ready to switch to a seat that stays in the car. A bigger seat just means you’ll be lugging around more bulk until that time.

And finally, do you need to have a car seat that clicks into your stroller? No. Do you want a seat that clicks into your stroller? Yes. Do you have to have a seat that clicks into your stroller? Absolutely.

"Until Puberty's Near, Keep Them Facing the Rear"

Okay, as catchy as that is I exaggerate. But one of the most controversial car seat issues is when to turn your kiddo to face the front. The clear American Academy of Pediatrics (AAP) recommendation is to keep your child facing the back until she turns 2 or meets the height or weight limits recommended by the carseat manufacturer. This part is tricky, because most seats are designed to face the rear until your kid is anywhere from 40-60 pounds. That’s about 8 years old! The rationale behind keeping young kids rear-facing for longer is that they still have relatively massive heads that can lead to neck injuries when flung forward. This makes intuitive sense, even though (as with child safety restraints in general) there’s still a lack of great evidence for it. The most important study, from 2007, used NHTSA crash data from 1988-2003 on kids under age 2. (1) The researchers found that front-facing kids were nearly twice as likely to get injured as those facing the rear. This difference was even more drastic for kids over 12 months old, with a 5-fold increased risk of injury when facing the front.

That’s pretty impressive data, but, in full disclosure, the study was actually retracted earlier this year when some statistical errors were discovered. Frustrating, but in these situations I like to apply the acronym WWSD – What Would Sweden Do? And those Swedes keep their generally large children facing the rear in their Volvos until about age 4. So, bottom line, keep your kid rear-facing until at least age 2 and certainly as long as possible if it’s working out. Parents can develop some angst when they see their 18 month-old’s legs bent a little bit, but kids are super flexible! She’ll be okay. I think there are two situations where flipping early could be reasonable:

1. Your kid has terrible carsickness and vomits nearly every time she rides facing the back.

2. Your kid screams hysterically for the entire drive when facing the rear, to the point where you feel that you are distracted as a driver.

Booster Battles

By the time kids turn 4, they are aware of booster seats and they want them. And you’re probably ready to stop dealing with those infernal latches and five-point harnesses. But be patient! As annoying as they are, harnesses simply do a better job of restraining your kid. Switch him to a booster when any of these 3 things are true (around age 6 for most kids):

1. He hits the weight limit of your car seat (often around 60 pounds but as high as 120, which is absurd. Your kid does not need his car seat during driver’s ed.)

2. His shoulders are above the highest slit for the shoulder straps

3. The top of his ears are at the top of the seat.

Once your kiddo’s in the booster, plan on keeping him there for a while. We’ve known for a long time that boosters until age 8 reduce injuries – by 45% over seat belts alone in a 2009 study. (2) The AAP’s recent recommendation to use them until the height of 4’9” (more like age 11-12) was mostly an educated guess. Last year, however, researchers looked at kids between the ages of 8 and 12 involved in crashes in Washington state. (3) They found that these older kids in boosters were 29% less likely to get injured in an accident versus those who used a seat belt alone. Given that only 10% of U.S kids in this age group use a booster, this should be an easy public policy decision. It’s also worth a little whining from your own kids to enforce it.

Boosters come with high backs and without. There's no data to show any safety difference, but I like the high backs until age 8 because they have side head flaps for naps and presumably better side impact protection.

Graduating to the Front Seat

The final question: when is your kid ready for the front seat? I guarantee she’ll start asking about it by age 5, but the right answer is 13 years old. The front seat is always a worse place to be for frontal collisions, and before 13 the explosive force of airbags can hurt kids as well. A 2009 study looked at over 10,000 crashes involving kids under age 15 and found that kids under 13 were only 1/2 to 2/3 as likely to get injured when sitting in the backseat versus the front seat. (4)

Alright, that wasn’t much fun, but we got through it. And at least now, when your kid says “But all my friends are doing it!” you’ll be ready to shut him down with some science.

1. Car safety seats for children: rear facing for best protection. Henary B et al. Injury Prevention. 2007; 13(6):398-402. doi: 10.1136/ip.2006.015115.

2. Effectiveness of belt positioning booster seats: an updated assessment. Arbogast, KB et al. Pediatrics. 2009;124:1281–6.

3. Booster Seat Effectiveness Among Older Children: Evidence From Washington State. Anderson, DM et al. American Journal of Preventive Medicine. 2017; 53(2): 210 – 215. doi: 10.1016/j.amepre.2017.02.023

4. Front versus rear seat injury risk for child passengers: evaluation of newer model year vehicles. Arbogast KB et al. Traffic Injury Prevention. 2009; 10(3):297-301. doi: 10.1080/15389580802677799


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