FAIRWAY, Kan. — Anne Epperson thought little of it when she flipped her daughter's convertible car seat around so she could face forward after her first birthday.
But if car seat advocates get their way, parents like Epperson will be delaying the switch, possibly for years.
The American Academy of Pediatrics is revising recommendations that they hope will clear up confusion regarding how long children should spend riding rear facing in car seats.
Some experts, citing a much-touted 2007 study, say tots are being put at risk switching to the forward-facing position at 1 year of age and 20 pounds, currently the minimum guideline from the pediatrics group and the National Transportation Highway Safety Administration.
That's because the extreme forces in some frontal crashes can jerk the heads of forward-facing children away from their immature bodies, creating a risk of spinal cord injuries. Rear-facing children are safer because their entire backs absorb the force of the crash.
The issue becomes confusing because both groups also advise that children are safer if they remain rear facing until the upper height and weight limit of their car seats. Many seats top out at 35 pounds in the rear-facing position, a weight many children don't reach until somewhere between their third and fourth birthdays.
It's rare in the U.S. for children to remain rear facing that long, although several countries require their youngest passengers to ride rear facing until they are 4 or 5 years old and 55 pounds.
The issue has attracted growing attention since a 2007 article in the journal Injury Prevention showed that U.S. children are five times less likely to be injured in a crash between their first and second birthdays if they are rear facing.
"We rarely, if ever, see spine injuries in children in rear-facing car seats," said Dr. Marilyn J. Bull, the contributing pediatric researcher in the study. "We will see head injuries or we will see a few other injuries, but the vast majority of serious injuries occur when children are forward facing."
The AAP is still discussing how it is going to revise the recommendations.
Dr. Dennis Durbin, who is leading the effort to update the group's policy on child passenger safety, said the emphasis will be more on remaining rear facing to the upper weight limit of the seat. The academy is hoping to introduce the new guidelines late next year.
Durbin said he is well aware of the research and said one of the goals with the revision is to reorder the policy and "really state what the ideal is."
That's good news to safety advocates.
"When it is written one year and 20 pounds, parents don't pay attention to the rest," complained Pam Holt, the previous chairwoman of the National Child Passenger Safety Board and the trauma prevention coordinator at St. John's Hospital in Springfield, Mo.
Count Epperson among the confused parents. The 35-year-old said she doesn't recall getting advice to keep her 23-month-old daughter or 3-year-old daughter rear facing longer.
"I've read a lot of books, but I've never heard that," Epperson said as she picked her daughters up from a church day care in the Kansas City suburb of Fairway, Kan. "I had no idea."
Pediatricians get some of the blame, said Dr. Benjamin Hoffman, part of an American Academy of Pediatrics committee that helps educate parents and doctors about injury prevention. The Albuquerque, N.M., pediatrician said some are still promoting old guidelines that say children must be turned forward at a year.
Hoffman, also a certified car seat technician, came across a mother recently whose pediatrician had given her that old advice, and she balked when he suggested she keep her 1-year-old son in the rear-facing position.
"I don't care what you think," she told Hoffman. "You aren't my pediatrician."
Stories like these make activists shake their heads. Motor vehicle crashes are the single leading cause of death for U.S. children, claiming an average of about four lives a day. Hoffman said it is tragic that "people are not operating on the best information they possibly could."
"The bottom line is that in a crash, a child who is rear facing is going to have all the crash forces spread over their entire back, from the tops of their head to the tips of their toes," Hoffman said. "And spreading all that force out over such a wide area significantly decreases the risk of injury."
Experts said part of the problem is that parents often have viewed switching their children to the forward-facing position as a rite of passage.
"It's like graduating from preschool into kindergarten," Hoffman said. "They view it as a good thing. What we need to do is work on changing people's attitudes so that they recognize that every step you make from rear facing to forward facing to booster, you lose some safety, and that people should switch only when absolutely necessary. It's not necessarily a negative step but neither is it a positive step.
"And the fact of the matter is the kids don't know any different. And if our first priority was to keep the kids as safe as possible, it would be a no-brainer."