In August, the American Academy of Pediatrics (AAP) issued a revised version of its policy statement titled “Child Passenger Safety.” The changes primarily affect the wording of recommendations for how long a child should ride rear facing. While the former version, issued in 2011, indicated that a child should stay rear facing until at least age 2 or older, the revised policy simply recommends that children stay rear facing as long as possible, until the height or weight limit of their RF CR is met (without making age 2 the rear-facing goal).
While this change removes the specification of age 2 from the AAP’s CR selection recommendations, it does not substantially change the policy’s guidance. Since the revised policy continues to recommend riding rear facing as long as possible, and the majority of convertible CRs on the market have a RF capacity that would allow the average child to ride this way beyond age 2, the change should not affect what’s encouraged for actual practice. (In fact, the revised policy statement continues to allude to age 2 in this way: “Most convertible seats have limits that will permit children to ride rear-facing for 2 years or more.” )
The change aligns the AAP’s CR selection policy even more closely with that of NHTSA. No changes were made to other aspects of the 2011 policy, although some supporting information was updated to reflect 2018 information.
The policy statement continues to include other helpful guidance of note. For instance, it mentions that certain considerations of the policy also apply to commercial airline travel, and it lists other policies that affect child transportation. It encourages pediatricians to keep their CPS knowledge up to date, to mention CPS at well-child visits, to be active in advocacy efforts, and to contact a CPST when needing assistance.
Why the AAP Made This Change
During routine review, AAP policy is retired, renewed, or revised every three years. Due to an update to key evidence that had been cited in the AAP’s 2011 policy (described in the SRN Nov/Dec 2017 issue), the AAP determined that a slight revision was necessary at this time. All available evidence continues to strongly support the safety advantage of keeping children rear facing as long as possible. However, research that had specifically tied this advantage for children up to age 2, a study of real-life crashes conducted by Henary, et al, was found in 2017 to have included statistical errors. This paper was subsequently retracted by the journal Injury Prevention, and therefore can no longer be referenced in any format. Researchers from the University of Virginia, the institution associated with the original study, re-examined the original data, as well as data from the ensuing years through 2015. Their updated study (McMurry, et al) showed evidence that it was safer to ride rear facing, but the sample size was not large enough to be statistically predictive of the general population at a reasonable level of certainty. In other words, it failed to have what statisticians call statistical significance.
Scientists do not rely on studies lacking statistical significance to form recommendations, so the McMurry, et al, study could not support specifying age 2 as a target for keeping a child rear facing. Since no other source furnishes a specific age recommendation, the age recommendation was removed.
What this means for CPSTs
Other evidence, like crash testing, child physiology, and experience in other countries, continues to strongly support the safety advantages of riding rear facing as long as possible. Since this was AAP policy (and, therefore, what CPSTs have been trained to teach caregivers), this update should not be a significant change to practice.
However, CPSTs who prepare safety materials to share with the public should review and update those materials to align with current AAP and NHTSA CR selection guidelines. In particular, check any reference to riding rear facing to age 2 carefully. References to that age that cite AAP policy or guidance should be revised. In general, safety messages should encourage keeping children rear facing as long as possible, until the CR’s height or weight limit has been met.
However, as in the AAP policy itself, there may be instances in which citing age 2 could continue to be appropriate (for instance, in the context of describing how long most CRs will accommodate the height/weight of an average child). Also, citing age 2 clearly remains appropriate in the many states with laws requiring children to ride rear facing until at least age 2.