Protecting Your Most Precious Cargo


This article was edited May 17, 2018 to reflect updated AAP and NTSB information. I retired from the Salem Pediatric Clinic July 29, 2016.

Suggestions from Dr. Tom and The American Academy of Pediatrics for car seat safety.

I distinctly remember traveling blissfully down 2,000 miles of gravel road on the Alcan Highway from my home in Alaska to “the lower 48” in the early 1960s. All five children and my parents rode in our Plymouth, not one of us wearing a seatbelt. Miraculously, we survived.

Sadly, despite years of intense educational efforts by the American Academy of Pediatrics (AAP) and the National Transportation Safety Board (NTSB), many children are not adequately protected when they ride in a car. Motor vehicle accidents remain the first or second most common causes of death in children 1 to 18 years.

As the AAP updated its recommendations in 2017, and on May 26, 2017 Oregon’s seat-belt law was strengthened, I would like to emphasize key recommendations.

All infants and toddlers must, per Oregon Law, be kept in rear-facing car seats until at least 24 months of age; further, the AAP strongly recommends children remain rear facing until they exceed the rear-facing weight guideline for your particular car seat. Despite the AAP recommendation in 2011 that children remain rear-facing until 2 years of age, a 2017 Journal of Pediatrics study found that only 62% of 491 surveyed parents of 17 to 19 month-olds reported using a rear-facing car seat.

Why are rear-facing car seats for young children so important? The simple fact is, a child is five times more likely to die if they are forward facing rather than rear facing in the event of a crash. Infants and young toddlers have proportionately much larger heads; as the vehicle dramatically slows (deceleration) during the crash, the brain of the forward facing baby is subjected to potentially much greater injury as it slams first into the front of the skull, then rebounds into the back of the skull. If this same child is left rear-facing, the brain and skull slow, or decelerate together, into the cushion of the back of the car seat, dramatically reducing the injury.

Many parents tell me they “had” to turn their child around by 18 months, “because he was just too big.” By this, they meant that his knees were somewhat bent facing the back seat. A very significant bend in a child’s knees might be uncomfortable on a long trip, but auto insurance crash data shows that rear-facing children suffer no increased broken bones in their legs from this position, even with the knees bent.

Children who are at least 2 years of age, or even safer, have reached the rear-facing capacity of their specific car seat may then use the 5-Point Harness in a forward facing position.

Belt-Positioning Booster Seats are legal in the state of Oregon when your daughter has reached 4 years AND 40 pounds. That said, both the AAP and the NTSB agree that a child is always safer in a 5-Point harness than in a booster. In fact, in every single progression, Rear Facing 5-Point Harness to Forward Facing, 5-Point Harness to Booster, and Booster to Adult Seat Belts, your child is ALWAYS safer in the former arrangement than the latter. It is, therefore, my strong suggestion that you delay moving to the next step as long as possible.

And now, what for me is the toughest “sell,” leaving your daughter in a booster until she is 57 inches tall. The state of Oregon, using AAP recommendations from the 1990s, passed a law stating that a child could be in a seat belt without a booster when they were 8 years or 57 inches. Sadly, the 2017 Oregon Seat-Belt law kept this language. In my opinion, this “or” is the most unfortunate participle of all time, as it should have said “and.”

What’s the big deal? Motor vehicle crashes, especially at high-speed will, in a child less than 57 inches tall, tend to cause the shoulder harness to ride up, causing potentially serious neck injuries. And seat belt will likely, in a shorter child, tend to ride up off the hips, causing blunt abdominal trauma.

The very tallest children, above the 97th percentile, will typically reach 57 inches at 8 years and 8 or 9 months. NO ONE is 57 inches tall at 8 years. And average children will be 11 or 12 years of age before they reach 57 inches. Because I felt this was so important, I started talking about the 57-inch recommendation at the 5 or 6 year check-ups, giving everyone time to get used to the idea.

So what if Billy is 9 years of age, 55 inches tall, and you already switched him to a seat belt? What should you do? Safest would be a return to the booster, but I realize that might be a battle. If you are unwilling or unable to move Billy to the booster all the time, I would strongly encourage you to at least insist on the booster for high-speed trips, such as on the freeway, or on a curvy state highway headed to the coast.

So why is it human nature for many caring parents to “bend” these recommendations and make potentially dangerous decisions to turn their child forward facing, or out of a booster, too early? Because we all live in the belief that “it will never happen to us.” Yes, the odds of a crash are statistically quite low. But if you always keep your child in the AAP and NTSB recommended car seats, you will live with the peace of mind that every time you drive away from home, you have done everything you can to protect your most precious cargo.

Below is the link to the AAP’s latest car seat safety recommendations, including an exhaustive list of currently available car seats, including their respective weight and height limits: