Alexandra Horowitz struggles to strap her daughter, Phoebe, 7 months, into her rear-facing car seat at a monthly infant/child car seat inspection held by the Montgomery Fire and Rescue at a Rockville car dealership. (Dayna Smith/FOR THE WASHINGTON POST)

When the American Academy of Pediatrics recently recommended that children ride in rear-facing car seats until at least age 2 — up from the previous minimum age of 1 — Internet news sites lit up with outrage. Many parents were hardly eager to embrace the latest medical advice about how to best protect toddlers from serious head, neck and spinal injuries.

“Do any of the folks who studied this have small children?” one wrote. “Have they tried to keep a squirrelly, anxious and frustrated 18-month-old rear-facing?”

“This is silly,” another wrote. “It would also increase safety to wrap kids in bubble wrap.”

Even parents at safety seat inspections held this month during Child Passenger Safety Week said they worry that the protests of rear-facing toddlers will lead to distracted driving and that little legs folded or scrunched up against back seats will be uncomfortable or unsafe.

Gail Provizer-Simmons of Rockville said she researched the safest minivan to buy and makes sure that her grandchildren are buckled up. But she said she had to turn her 3-year-old grandson’s seat forward when he was 10 months old “or his legs would have been through the back of the seat.”

The latest recommendation is not a legal requirement, though safety seat advocates say state laws often lag behind what they consider best practices. (Dayna Smith/FOR THE WASHINGTON POST)

“I honestly don’t know how this is going to work,” Provizer-Simmons said recently at a Fitzgerald auto dealership’s safety seat inspection in North Bethesda.

She pointed to her 8-month-old granddaughter, Emma Railey, sleeping in a rear-facing infant seat, her tiny feet almost touching the back of the seat. “Where are you supposed to put the kids’ legs?”

Safety experts say their recommendation on rear-facing car seats will require a more concerted public-awareness campaign for several reasons.

Keeping children in rear-facing seats longer can seem counterintuitive to parents, many of whom have come to consider turning the safety seat around as a first-birthday rite of passage.

Unlike in Sweden, where safety seats are designed to provide adequate leg room for rear-facing children up to age 4, U.S. safety seats are made to fit snugly against the back of the vehicle seat, leaving little room for growing limbs. Not to be discounted, safety experts say, is the particularly difficult developmental phase of the children affected: squirmy toddlers who resist being confined in safety seats facing in any direction.

“I don’t think we’ve done an adequate job of explaining to parents why their child needs to be rear-facing,” said Dennis Durbin, who is a doctor, lead author of the pediatric group’s recommendation and co-director of theCenter for Injury Research and Prevention at Children’s Hospital of Philadelphia.

“I think if more parents understood why it’s safer,” Durbin said, “most would gladly delay” turning car seats around.

‘Properly restrained’

The latest recommendation is not a legal requirement, though safety seat advocates say state laws often lag behind what they consider best practices.

No state requires that children sit in rear-facing seats after having their first birthday or reaching a weight of 20 pounds, according to the Insurance Institute for Highway Safety. The District and many states, including Maryland and Virginia, require that children up to age 8 be “properly restrained,” according to the manufacturer’s instructions, in a harnessed car seat or belt-positioning booster seat. All manufacturers of convertible safety seats — the kind that can be rear- or forward-facing — say in the instructions that the seat must be rear-facing until the child reaches 1 year and 20 or 22 pounds, local officials said.

Child safety specialists said they have long known that rear-facing is safest for all ages. They previously recommended “until at least 1 year and 20 pounds” because that was the weight limit manufacturers put on rear-facing seats. But to meet the growing demand from parents of overweight babies and young toddlers, such seats are designed to carry rear-facing children up to 45 pounds — about the average weight for a 5-year-old boy.

Riding in a rear-facing seat is particularly important for children, medical experts say, because their heads are relatively heavy and their necks and spines are less developed. In a crash, doctors say, children’s heavy heads can snap forward with a force that can break their necks, injure their spinal cords and cause severe brain injuries. When rear-facing, the safety seat cradles the head and neck, keeps them properly aligned and spreads the crash forces across the entire body.

A 2007 study published in the medical journal Injury Prevention found that children younger than 2 were 75 percent more likely to die or be seriously injured when facing forward.

As for the limited legroom, pediatricians say children are far more flexible than adults, which allows them to sit comfortably with their legs folded for long periods. Moreover, studies show that leg injuries are relatively rare in rear-facing children and are more common in forward-facing children. Most important, doctors say, leg injuries are far less serious than the head, neck and spine injuries that they see in forward-facing children.

A matter of legroom

Parents say — and safety advocates concede — that a lack of leg room limits some children from sitting in rear-facing seats as long as safety experts would like. U.S. safety seats must meet federal testing requirements when strapped in using only a lap belt — the most basic restraint found in all U.S. passenger vehicles made after 1968. That requires the safety seat to fit snugly on the vehicle seat. U.S. safety seats also are designed to attach tightly to the seat back via shoulder belts or LATCH (lower anchors and tethers for children) system anchors embedded in the vehicle seat crevice.

In Sweden, where children use rear-facing seats until age 4, safety seats allow more legroom because they can be positioned farther from the back of the vehicle seat and closer to its edge. But those seats must be supported by a metal leg or base that attaches to the vehicle floor. Such support legs are not allowed under U.S. safety standards.

Ronald Medford, deputy administrator of the National Highway Traffic Safety Administration, said there is a significant benefit to having a child, regardless of age, ride in a rear-facing seat, up to the seat’s maximum height and weight. Even so, he said, “I do think there are design limitations. It’s a balance between realistic designs and where kids can be comfortable.”

David Campbell, a Cleveland-based safety seat technical consultant to the Juvenile Products Manufacturers Association, said parental demand hasn’t caught up to the new recommendation. Rear-facing car seats like those manufactured in Sweden would be more expensive and more complicated to use, he said.

Children’s legroom also is limited because a safety seat properly placed on a vehicle’s back seat shouldn’t hit the front passenger or driver’s seat, often a tight squeeze in compact cars, he said.

“I think most people are keeping their children rear-facing to a year,” Campbell said. “They understand the recommendation to keep them rear-facing longer, but I think people think they’ve met the most important need and then turn them around.”

Parental attitudes

Marilyn Bull, a doctor and a safety specialist for the American Academy of Pediatrics, said parental attitudes are as big an obstacle as limited legroom. Bull said she hears parents say they’re worried that they will delay a developmental milestone, akin to walking or talking, by keeping a child riding backward after one year.

“I think the mind-set, socially, was: ‘My child is smart and babbling and sitting up by himself, so he can sit facing forward,’ ” Bull said. “Now I tell my medical students it’s the smarter, more creative parent who keeps their child riding backwards longer.”

In answer to those who roll their eyes, remembering when children bounced around with no seat belts, experts say child safety seats have led to a 71 percent drop in crash-related infant deaths and a 54 percent reduction in such fatalities among 1- to 4-year-olds, according to NHTSA statistics comparing 1988 and 1994 crash data. Motor vehicle crashes remain the leading cause of death for children ages 3 to 14, according to NHTSA.

The basic message about the importance of safety seats appears to be getting through. At the recent safety seat inspection in North Bethesda, some parents said they will find a way to follow the experts’ advice.

“We’ll do whatever the recommendation is,” said Michelle Moore of Potomac. Her 4-month-old daughter will ride facing backward until age 2, she said, even though she turned her two sons’ seats forward at one year, in keeping with the previous recommendation.

“I think kids just adapt,” Moore said. “If that’s what they’re used to, they won’t know otherwise.”