Objectives The National Highway Traffic Safety Administration and the American Academy of Pediatrics recommend children be placed in rear-facing child restraint systems (RFCRS) until at least age 2. These recommendations are based on laboratory biomechanical tests and field data analyses. Due to concerns raised by an independent researcher, we re-evaluated the field evidence in favour of RFCRS using the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) database.
Methods Children aged 0 or 1 year old (0–23 months) riding in either rear-facing or forward-facing child restraint systems (FFCRS) were selected from the NASS-CDS database, and injury rates were compared by seat orientation using survey-weighted χ2 tests. In order to compare with previous work, we analysed NASS-CDS years 1988–2003, and then updated the analyses to include all available data using NASS-CDS years 1988–2015.
Results Years 1988–2015 of NASS-CDS contained 1107 children aged 0 or 1 year old meeting inclusion criteria, with 47 of these children sustaining injuries with Injury Severity Score of at least 9. Both 0-year-old and 1-year-old children in RFCRS had lower rates of injury than children in FFCRS, but the available sample size was too small for reasonable statistical power or to allow meaningful regression controlling for covariates.
Conclusions Non-US field data and laboratory tests support the recommendation that children be kept in RFCRS for as long as possible, but the US NASS-CDS field data are too limited to serve as a strong statistical basis for these recommendations.
- motor vehicle occupant
- child survival
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Contributors TLM, KBA, CPS, FV, MB, JRC and RWK each contributed to the manuscript. TLM contributed to the planning, conduct and reporting of the work, and is the guarantor of the overall content. KBA contributed to the planning, conduct and reporting of the work. CPS contributed to the planning and reporting of the work. FV contributed to the reporting of the work. MB contributed to the reporting of the work. JRC contributed to the planning of the work. RWK contributed to the conduct and reporting of the work.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data are publicly available from NHTSA: https://www.nhtsa.gov/research-data/national-automotive-sampling-system-nass.