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Melanie Cole (Host): One of the most important jobs you have as a parent is keeping your child safe when riding in a vehicle. Each year, thousands of young children are killed or injured in car crashes. Proper use of car safety seats helps keep children safe, but with so many different seats on the market, many parents find this very overwhelming. My guest is Lisa Allee. She's the Director of Injury Prevention at Boston Medical Center. Lisa, when we talk about all of these car seats, and there are so many of them on the market today, what is the first most important bit of information you want to share with the listeners? What do you tell them every single day is the most important thing to know about car seat safety?

Lisa Allee, MSW, LICSW (Guest): So the most important thing to know really is that the best seat for you is the one that fits in your vehicle the best, and the one that you will use correctly every time. So all car seats are crash-tested the same way and pass the same sort of standards through the National Highway Traffic Safety Administration. And so when you're looking at car seats, it's really what's going to be easiest for you to use and which one fits in your car? There are so many different vehicles and car seat combinations, but that often can be very difficult for parents.

Melanie: So then let's start with our little guys. What ages and sizes? Let's talk about the car seats and basically starting with rear-facing. So our little newborns leave the hospital, you can't even leave the hospital without a car seat in your car. So speak about the rear-facing newborn seats, and how long they should be used.

Lisa: Yes, all infants should be leaving the hospital with a properly fitted rear-facing car seat. And so children can fit in rear-facing car seats up to the upper weight and height limits of that particular seat. Because there are so many choices, some of those car seats can fit a child up until twenty pounds, some are thirty-five pounds, so it's really going to differ based on the manufacturer of the car seat and their guidelines. It's very important to read the booklet and be familiar with your particular car seat. In that, we say even when your child has reached the upper weight and height limit of that rear-facing bucket seat or convertible seat, you should try to keep them rear-facing as long as possible. So if you do have a traditional bucket seat, which are those seats that you can carry, they pop in and out, they connect to strollers, and do all sorts of great things to make it easy and mobile for you and your infant, we do recommend that the children then go to a convertible seat and stay rear-facing as long as possible up to three years old.

Melanie: So up to three years old, that's age-related. Now sometimes you're going to have a two and a half year old that does not want to face rear-facing. What's a parent to do?

Lisa: So the conversation I have with parents often is that it's not typically the child, it's more of the parents' desire to want to be able to see their child, to have it easier, to be able to hand them things and pass things in the vehicle. And so typically children, if they're used to being rear-facing, they're quite comfortable in that position. When we think about safety and why we suggest that children stay rear-facing until they absolutely have to turn around, and again I say between two and three years old, it really depends on their height and weight limit more than the actual age.

So we usually tell parents that it is really the parent and not the child who's typically as concerned, and although it seems like it'll make it easier, your child's spinal cord and neck are not as strong as they could be to turn them around. It's much safer to keep them rear-facing. In other countries, in The Netherlands, they keep all children rear-facing until they're three, and they have one of the lowest rates of mortality and spinal cord and neck injury in their children crashes.

Melanie: Lisa, while we're talking about the little guys, people tend to in the wintertime bundle up and then put the child in a car seat, or they think the car seat’s not comfortable so they put little bumpers on it, or they put little pads on the seatbelt part of the car seat. So speak about adding those little things onto the car seat and really what should we be doing when we put baby in there?

Lisa: Great, great question. So absolutely we see this all the time. People want to make their child more comfortable and think that by adding things, this will do so. So in reality, you shouldn't add anything extra to a car seat that doesn't come with your car seat or is distinctly noted to have been crash-tested with your particular car seat. Children should go in those seats just like they're provided when they come out of the box with no baggy clothes on, no winter coats or bundles, and really be able to just go in there with a single layer of clothing so that the straps are nice and fitted, so that you're not able to pinch the straps, and then they can have blankets go over them to keep them warm.

Melanie: Do we put them in the middle of the backseat? Do we put them on either side? Is there a side that's safer, the driver's side or the passenger side? Where do we put it?

Lisa: It's really what's best for that particular family. In the past there have been recommendations that infants be in the middle position, but that's not always the best fit for the car seat. So it depends on your car and the car seat. Some vehicles you can't even install a car seat in the middle position, it's not safe. Others have a bump in the middle so you can't get them tight enough, so it's really dependent on the car and the car seat and that family.

The other thing that makes it difficult, having them in the middle, is that you have to lean very far into the seat, and as the child begins to grow and get heavier, it can lead to moms and dads having back problems and back injuries from that. So we do try to consider everything.

In reality, most cars now have lots of great side-impact protection, so we're not quite as concerned as back twenty years ago when we didn't have any of that and thought the middle position would be best in case of a side-impact crash.

Melanie: What about convertible seats? So sometimes now you can buy a seat that starts as a little rear-facing, and pops out and goes onto a stroller, and then it can be turned around for a front-facing, and then it can even have little wheels that drop out and become- you know, there are so many of these on the market now. Is that okay to use these convertible seats or do we want separate seats for each age and stage?

Lisa: You know, the amount of technology that's out there now, being able to make these seats completely convertible from beginning to end, those are absolutely fine. They beat all of the crash-test standards. They tend to be rather expensive, the ones that kind of have that full capability to pop in and out, turn around, strap into all sorts of different strollers and such. So it's really what's best for the particular family, but all of them are crash-tested to the same standards, including those.

Melanie: So now we're moving onto front-facing seats, and again, based on size and weight and age, we're kind of considering all of these things, now your child is front-facing. When then does it become the front-facing seat with a seatbelt or a booster? Because little kids, then they start to want to use that booster and feel like a big kid.

Lisa: Yeah, so we really recommend anywhere between four and seven years old that your child is able to move up to a booster based on height, weight, and how often the child is going to be reliable with keeping that seatbelt strapped, with keeping their bum all the way back up against the back of the seat and they're not slouching. The primary problem we see with the seatbelts and the booster in young children is that they tend to slouch to try to get their feet to touch the ground, and then the seatbelt moves up over the abdomen, which is where we don't want it in a crash, where it can cause some pretty significant internal injuries.

And so we do tell parents, our recommendation is to keep them in a forward-facing car seat with a full five-point harness until they reach the upper weight and height limit of that, even if there are boosters that do fit them at that weight, to really keep them as safe as possible as long as possible.

Melanie: So what do we want to know about seatbelts? What's important to know about how they fit when your child becomes ten, eleven, twelve, and they're not in a booster seat anymore, but they are still in the backseat, and they are with a seatbelt, what do you want us to know about how that should fit?

Lisa: Yeah, so the seatbelt should fit snugly across the shoulder and chest, never across the neck or the face, and it should lie nice and tight along your upper thigh, so not the stomach, but kind of all the way down the lap belt part of it, laying across the upper thighs. So again, one of the things that I tell kids is that if they can sit it all the way back to the very back edge, it typically keeps the seatbelt in the correct position.

Melanie: So wrap it up for us, Lisa. What would you like parents to know - and you do this every day - about making sure that they're using the proper safety car seat for their child and for their vehicle, how to know that it's fitted properly, where they can go for more information about how to get it fitted? What do you want them to know?

Lisa: I want them to know that it's wonderful that they're concerned and wanting their child to travel safely. I think it's one of the most very important things that a parent can do throughout their child's life. If they go onto the www.BMC.org main website, under programs and services, we have a link for child passenger safety. It not only gives a couple- three car seat guides put out by Safe Kids and NHTSA, but it also has links to scheduling a car seat check with the City of Boston, scheduling a car seat check with us here at Boston Medical Center. There are people out there who are certified Child Passenger Safety Technicians and they really have all of the information that you need. So please get your car seat checked, make sure you're using it right, that's what we're here for.

Melanie: Thank you so much, Lisa, for sharing your expertise with us today. Such an important topic for really all parents to hear. This is Boston MedTalks with Boston Medical Center. For more information you can go to www.BMC.org. That's www.BMC.org. This is Melanie Cole, thanks so much for tuning in.