This spring, the American Academy of Pediatrics (AAP) published a policy statement officially recommending that it is safest to remain in a rear facing car seat until at least the age of 2 years or until reaching the highest weight and height allowed by the manufacturer. The U.S. National Highway Traffic Safety Administration (NHTSA) recommends that children remain in a rear facing seat until they have reached this weight and height limit, even if it is past 2 years of age. While there is solid evidence supporting this recommendation, many parents are struggling to implement it – leading to lively discussions on blogs, in play groups, and even in a recent front page article in the Washington Post.

Most pediatricians have been in this situation before: You present what seems like a simple and straightforward recommendation, and parents look at you as if you are crazy. So, what is the evidence, and what are the concerns voiced by some parents?

A 2007 study by Dr. Basem Henary and colleagues looking at data extracted from the NHTSA vehicle crash database for the years 1988-2003 involving 870 children found that children aged 0-23 months in forward-facing car seats were significantly more likely to be seriously injured than children in rear-facing car seats. This finding held up when specifically looking at the subgroup of 12- to 23-month-olds (Inj. Prev. 2007;13:398-402). Rear-facing car seats provide more even support to the head, neck, and torso for young children, as anyone who has seen a child asleep in their forward facing car seat with their head slumped over can attest. Interestingly, in Sweden it is common practice to remain in rear-facing car seats until the age of 4 years, also with reported reductions in injury.

Still, some parents report a reluctance to follow these recommendations – but why?

• "My child’s legs seem cramped, and I’m worried they might be injured." Lower extremity injuries are extremely uncommon in children who are in rear-facing car seats during crashes. In fact, this type of injury is likely more common in children facing forward, as their legs swing and thrash about, banging into things. Additionally, a toddler’s natural sitting position often involves them curling up their legs, and so bending their knees to fit into a rear-facing car seat is not uncomfortable to them.

• "My child screams nonstop while facing backward in their car seat, and it is distracting while I drive." Although this may certainly be true, what is most likely is that 1-year olds-often hate being in any car seat – whether it faces forward or backward! Helping parents to think about ways to (safely) distract and entertain their child while in the car can be a useful technique. And if this doesn’t work (which it sometimes doesn’t), provide reassurance that it is okay to let your child cry, and eventually he or she will get the idea that it just isn’t going to change anything.

• "I have a compact car, and the car seat just doesn’t fit well backwards." This also can be true, and can be difficult to address. Encourage parents to do careful research before buying a convertible car seat to ensure they buy the one that fits best in their car; both AAP and NHTSA have resources families can use. Parents also should be encouraged to use local car seat fitting stations as a resource, as they have training in addressing difficult car seat fit situations.