March 21, 2011 -- It is a rite of passage for many parents: the moment their infants can be switched from the rear-facing car seat to a forward-facing seat.
"They were able to see us," said Asanga, a Potomac, Md., mother of 2-year-old twins who declined to give her last name.
Her husband, Joseph, added, "We could point things out to them. We could tickle their toes."
Parents have been told for years that they can make the switch when infants reach the age of 1 and weigh at least 20 pounds. But the about-face would be delayed substantially under new child car-seat recommendations released this morning by the American Academy of Pediatrics (AAP) and the National Highway Traffic Safety Administration.
"The first recommendation [is] that all infants and toddlers remain in rear-facing car seats until age 2, or until they outgrow the height and weight limits of the seat," said Dr. Dennis Durbin, a pediatric emergency physician at Children's Hospital of Philadelphia and the lead author of AAP's new policy statement.
The American Academy of Pediatrics's last car-seat recommendations dated from 2002. "There has been some evidence that's come out since the last recommendations were issued, that suggest that kids up to age 2 who stay rear-facing are at a significant lower risk of injury in a variety of crashes," Durbin said.
"When you're facing the rear of the vehicle in a seat, the child is sort of cradled and supported by the structure of the seat," he said, "If they're forward-facing, their trunk and their shoulders might be well restrained by the harness straps, but their head and neck are often left free to sort of whip forward in the event of a crash."
Durbin added that many infant car seats, and so-called convertible seats, which can be used for both infants and toddlers, can now accommodate larger children in rear-facing positions. With some seats, children up to 35 pounds can face backwards.
The government agrees with the new push to keep children rear-facing as long as possible. "I think it really does reflect the, not only the state of the art, but also the science that that doctors have recognized as what's the best thing for the child," NHTSA Administrator David Strickland said.
For children older than 2, the AAP advises parents to keep children in a seat's five-point harness as long as possible, up to the height and weight limit of the seat, before switching to a booster seat for use with the car's seatbelt.
The guidelines for elementary school children have been changed as well. Previously, parents were advised to keep children in booster seats until about age 8. Booster seats do just that; boost a child up higher so that the car's seatbelt fits properly over the child.
Both the government and the AAP now say it's not age that matters but the size of the child. "The prior recommendations were really based on age, and it did not take into account that different children have different cycles of growth, and I think the recommendations recognize that," Strickland said.
The new recommendations stress that children should remain in booster seats until they reach 4-feet 9-inches tall, when the seatbelt should fit properly across their chest and lap. That could mean children could stay in their booster seat until age 12.
Zack Zindler, 9, of Bethesda, Md., didn't like that idea. "Bad," was his one-word reaction to the notion that he could still be sitting in a booster.
"He thought it was very cool when he got to the seatbelt," mom Jamie Zindler said. "Once their friends get out [of the booster seat], they don't want to do it."
Zindler said she moved him out of the booster in the past few months, based on previous recommendations that the seats were for children through age 8.
Any parent knows continued booster-seat use could be a hard sell. "Traffic crashes are the largest killer of children, period," NHTSA's Strickland said. "Just because your child may not be happy about having to be in a booster seat a little bit longer, I think you would rather have to deal with that situation than having your child sustain an injury that could have been avoided if they were in a properly fitted restraint."
Durbin of Children's Hospital, who has treated many young car-crash victims, said children have become expert negotiators. But he advises families that "safety really should not be negotiable."
Forty-seven states and the District of Columbia require booster-seat use for older children but the age limits vary widely. Tennessee and Wyoming have the strictest laws, requiring booster seats through age 8. A dozen states require their use only though age 5. There are no booster seat requirements in Arizona, Florida and South Dakota.
Strickland and Durbin agree it can be confusing for parents when state laws don't match up with government and pediatrician recommendations. They said they hope the new recommendations convince state governments to take another look at their car-seat laws.
"There's no question in my mind that consistent following of these recommendations will help parents ensure that their children are as well protected as they can possibly be in the event of a crash," Durbin said.
Amy Graham, the mother of 6- and 3-year-old boys, said she has no issue with the new recommendations. "If there's evidence that it improves safety, she said, "it makes sense."