A pediatrician addresses parents' concerns and confusion about the American Academy of Pediatrics' new car seat safety guidelines.

Many parents have expressed confusion about the American Academy of Pediatrics' new car seat guidelines, which recommend that toddlers stay rear-facing until age 2, or until they reach the height or weight limits for their rear-facing car seat. So we asked Alisa Baer, M.D., a New York City pediatrician known as The Car Seat Lady, to address parents’ most frequently asked questions, from worries over the child’s discomfort to fitting rear-facing seats into a small car. 

What if I have a small car that won’t fit my convertible seat rear-facing, or won’t fit two rear-facing seats?

Having installed more than 5,000 car seats, I can tell you that the overall size of your car or car seat don’t matter as much as the distance between the back seat to the back of the front seat. Also at play is how the back of the front seat is contoured, as some vehicle seats protrude more into the back seat's territory than others. 

When picking a car seat to go in the center of the back seat, pick a car seat that is more contoured at the head area; those that are more squared off or rounded will have difficulty tucking themselves between the two front seats (see the photo above to see what I mean). These two convertible car seats are the same width, but the one on the left is much more contoured at the head area and will therefore tuck itself nicely into the gap between the two front seats, while the one on the right will often not. 

When picking a car seat, especially one that will be going behind the driver, the best one will be the seat that can sit the most upright when installed rear-facing.  When you are in the store, see how much room the car seat takes up front-to-back when it is in the most upright position allowed for rear-facing by the manufacturer.  The sloping of your vehicle seats will also determine how reclined or upright the car seat sits; the more sloped the bottom of the vehicle seat, the more upright the car seat will tend to sit, and the more room it will typically allow for a front seat passenger.

If you are curious which car seat currently on the market has the smallest footprint in terms of front-to-back distance, the answer is the Combi Coccoro.  Its drawback is that it is also shorter in seated height than most convertibles, so won't last rear-facing as long as others. But it may be an option for a family with two rear-facing kids, especially in a small car with a tall driver where one child has to go behind the driver’s seat.

Confused? Visit www.seatcheck.org to find a trained technician in your area who may be able to help you arrange the seats securely in a way that maximizes the space for everyone in the vehicle.

Won’t my child’s legs be squished? I don’t want her to be uncomfortable.

Kids are flexible.  Your baby spent the last 4 months of your pregnancy tucked up into a little ball; as a newborn all he wanted was for you to swaddle him as tightly as possible, tucking his knees up as high as they'd go, to keep him calm.  Your 6-month-old thinks that chewing on his feet is the best activity ever.  Your toddler may no longer want to be swaddled or teethe on her toes, but I'm sure she sits in some pretty contorted positions when playing on the floor with her toys.  Ever try sitting in a "W" like your toddler often does? I'll bet you haven't, because adults typically aren't flexible enough.  Ever watched a 5-year-old sleep with his chin on his chest during a long car ride and think "ouch, that can't be comfortable," yet your 5-year-old amazingly wakes up happily with no complaints of a stiff neck? Kids are flexible because their joint spaces aren't fully formed; since they aren't fully formed in their knees and ankles, your rear-facing preschooler is able to sit comfortably even though they appear somewhat cramped.

Many parents also worry that it is unsafe for the child's legs to be bent in a crash.  Won't they break a leg?  Could their knees go into their stomach and hurt them this way?  Turning to data from real kids in real crashes, we know that the answer is NO—they typically won't break their leg, and we have not seen any abdominal injuries.  In fact, studies show there are many more leg injuries to forward-facing children than to rear-facing children.  As a pediatrician, I worry most about the brain and spinal cord, as these are the parts of the body we don't know how to fix if they get broken. Rear-facing protects the brain and spinal cord much better than forward facing.  A broken leg should be the worst injury your child has; six weeks in a cast, and they are as good as new.

What if I get hit from behind? Is my child safe rear-facing?

You know the saying “don't sweat the small stuff?” Well, it even applies to rear-end collisions, as they typically are the least severe of all crashes.  If you look at crashes from 2009 that were severe enough that at least one person in the vehicle died, only 4% of those crashes were rear-end collisions; 52% were frontal impacts, 27% were side impacts, and the remaining 16% were other types, mostly rollovers.  Therefore, it is most important to provide protection for frontal and side impacts, because these crashes tend to be the most deadly. 

What if my child gets motion sickness from sitting backward?

As someone who, to this day, still gets very motion-sick, this is a topic near and dear to my heart.  Motion sickness happens when the brain gets mixed messages about motion and can't reconcile them; your body feels stationary as you sit in the car but your eyes tell your brain that your body is actually moving.  When the brain can't figure out how to make sense of these seemingly contradictory messages, the body feels sick.  Volvo did a large study of several thousand toddlers and found no difference in the rates of motion sickness between those riding rear-facing and those forward-facing.  But statistics don't help when it is your child who is throwing up!  Here are some suggestions.

The most important thing is to make sure your child has the best view possible out the BACK window.  Kids and adults who get motion-sick will tell you that looking out the side windows is a quick and easy way to feel very sick, very fast.  Why? Things move very quickly out the side windows, which confuses the brain even more.  Looking out the back window (for rear-facing kids) or the front window (for forward-facing kids or adults) makes it seem like you are moving slower than the side windows make it seem.  For rear-facing kids, sit their car seat as upright as the manufacturer allows and, when possible, remove the vehicle's head rest to give the child the best possible view out the back window.  If possible, have the child ride in the center of the back seat as this spot typically gives the best view out the back window.  You may want to consider trying to block your child's view out the side windows, since you can't really tell a 2-year-old not to look out the side window!  This sunshade will do just that.  

Make sure you aren't inadvertently making your child feel sick; if you are giving him toys or books that require looking down and concentrating, this will likely make him feel sick.  Try occupying your child with songs and games that require looking out the window.  If you can, travel at naptime or bedtime as your child will not feel sick while sleeping. 

Many parents use food as an activity during long car rides, but for a child who gets motion sick, this will only make matters worse.  Feed your child something starchy like bagel or crackers about 1-2 hours before the car ride, and then try to not feed him in the car.  

If you have to take a long trip, talk to your pediatrician about using an anti-nausea medication.  You can also try some natural, homeopathic remedies, including accupressure wrist bands (but make sure the one you get is not a choking hazard for a young child), and ginger.

Some kids are going to get motion sick regardless of the direction they are facing—and the worst part, besides watching your child feel ill, is having to clean the car seat when it is full of vomit.  To decrease the clean-up, have your child wear a "puking poncho" that keeps his clothes and the car seat dry.

What should I do if my kid hates rear-facing and screams through every car trip? I’ll be a distracted driver, and that’s not safe either.

As a pediatrician, I can tell you that it is not developmentally appropriate for a toddler to want to sit happily in the car for long period of time, no matter which way they are facing. Toddlers are curious by nature and want to run around and explore their world, something which car seats (whether rear-facing or forward-facing) don't allow.  But sometimes as parents we subconsciously encourage the very behavior we want to discourage. For example, when your child is screaming in the car, you probably give them more attention (telling them to be quiet is attention, albeit negative attention) than when they are playing quietly in the car.  To your child to sit happily in his rear-facing car seat, you are going to need to put in a little effort, but I can guarantee that the pay off is worth it for both of you.  Here are some suggestions; try whichever one or ones you think may work best with your child.

The first thing to understand is that young kids will work for attention—whether it is positive or negative attention—and they likely have trouble distinguishing between the two.  First, you need to praise your child frequently for good behavior.  If you are buckling your child in and he is cooperating nicely say, "Mommy is so proud of you for getting buckled like a big boy.”  It is now two minutes into the car ride and he's still sitting nicely; yup, you guessed it, praise him again.  Two minutes later, praise him yet again.  Kids have very short attention spans, so the praise, especially in the beginning, needs to be very frequent.  But what happens when he starts to scream (as he will invariably do)? First, stay calm.  Your goal is to give him zero attention for his misbehavior; this means that you don't show him any facial expressions in reaction to it (typically people show an angry face or laugh, both of which encourage the child to continue screaming).  Instead of asking or telling the child to be quiet you can either ignore them completely or, using a normal tone of voice, talk with them about something else (pretend that they aren't screaming and are acting normally). 

Another way to praise the child for good behavior is using a sticker chart.  Kids love visual reminders of their good behavior, and it encourages them to continue that behavior so they get another sticker.  If your child often misbehaves when you are buckling them in, talk to them on the way to the car about the behavior you expect and the reward for such behavior (i.e. a sticker, or getting to read a story with you).  If they behave well while you buckle them in, don't make them wait until the end of the car ride for a sticker, give them one then.  If they also typically misbehave during the trip, talk to them on the way to the car about the behavior you expect, and give them a sticker at the end of the car trip as a reward. 

Making things routine—and helping your child understand the steps to the routine—alleviates some of the anxiety associated with change. Picture books are a great way of teaching your child the rear-facing routine, while also making it fun. Most toddlers love reading books, especially ones about them!  Here is an example of a story you can write with your child; you can even take your own photos to add to it. Print it out and read it with them as you go to the car and buckle them in.

Page 1: Mommy and I walk to the car.
Page 2: Mommy opens the car door.
Page 3: I climb into my seat like a big girl!
Page 4: Mommy puts the straps over my shoulders and over my hips.
Page 5: I help Mommy with the easy part (the chest clip). 
Page 6: Mommy does the hard part (buckles between the legs).
Page 7: Mommy makes my straps snug so they give me a hug.
Page 8: Mommy gives me a high five and a hug.
Page 9: Mommy sits in her seat and wears her seat belt snug so it gives her a hug.
Page 10: Mommy starts the car—I like the sound of the engine! 
Page 11: Off we go!

If your child has a favorite book or small toy, save it for the car. This way it makes them look forward to riding in their car seat, as they get to play with that toy or read that special book. 

A new study seems to come out practically every day. How do I know the studies on rear-facing car seats won’t change tomorrow?

Physics don’t change, and the physics is such that forward-facing will never be safer than rear-facing, as this video clearly demonstrates.  We'd all be safer riding rear-facing!  Ever wonder why flight attendants ride rear-facing? You guessed it—because rear-facing is the best way to take an impact.  With more than 30 years of data from Sweden, where kids ride rear-facing until age 4 or beyond, showing the benefits of rear-facing over forward-facing for toddlers and preschoolers, I can assure you that the only changes in the recommendations will be to increase the time kids should ride rear-facing, not decrease it.  While these recommendations may seem new to many parents—specifically that kids should ride rear-facing as long as possible and in boosters until the belt fits properly (typically age 8-12)—they aren't actually new at all.  Even in 2002, the American Academy of Pediatrics said for optimal protection, the child should remain rear-facing until reaching the maximum weight for the car safety seat, as long as the top of the head is one inch below the top of the seat back.

How do you get your child in the car without bashing his head on the top of the car?

Ever find your toddler on the kitchen counter with his hand in the cookie jar?  Toddlers are great climbers; put their skills to good use and teach your toddler how to climb into their car seat.  It may take a little practice to find the best way for them to climb in, so take a few minutes one day when you aren't in a rush to go anywhere, and teach your toddler.  Make it a game and they'll think it is fun!

For younger kids who can't climb in by themselves, put them into the seat diagonally, with their head first and feet last.   

My child is 15 months old and forward-facing. Should I really turn him back rear-facing?

Yes!  When we know better, we must do better.  Three months ago when you turned her forward facing, you did what you thought was best, but now you know differently.  Avoid regrets, and give her the best protection you know how.  

Many parents worry that it will be a disaster turning a child back to rear-facing.  Here is one mom's experience turning her almost-3-year-old son back rear-facing:

“I was initially very hesitant to move my almost 3-year-old son to rear-facing from forward-facing.  He has been sitting forward-facing for over a year and can be strong-willed when it comes to change.  However, after hearing how much safer it is, I was willing to try.  The first three or so drives were very difficult, as he asked to "look out mama and dada's window" almost the entire time. We ignored and distracted, and I was about to give up when I noticed that although he still complained about sitting rear-facing, it happened less and less.  Now (after about three weeks) he asks maybe once every other drive if he can sit forward-facing and was even (mostly) fine the other day when his friend joined us and sat forward facing.  It was a tough first few drives, but I am very happy we did it and I feel so much safer.”

My 20-month-old is too heavy for rear-facing in her current seat. Should I really buy a different seat just so she can ride rear-facing for a few more months?

Imagine it is November, and your 20-month-old has outgrown all of her winter clothes.  Would you not buy her new winter clothes because it will be warmer in 4 months?  The car seat is one of the only products you will ever buy for your child that has the potential to save her life.  Just like your child needs new clothes frequently, they may need a new car seat sooner than you thought.  If you are in a crash, you will be relieved knowing that you gave her the best protection possible.