Seattle Mama Doc

A blog by Dr. Wendy Sue Swanson.

A mom, a pediatrician, and her insights about keeping your kids healthy.

5 Ways To Protect Babies And Children In The Car: No Age Limit For Rear-Facing Car Seats


Unbelievable coincidence today: I stayed back this morning to finish this post while my family dropped off my son for a birthday party. There are complex carpools happening to get to the party (thank you, Village!) and while sorting it out someone offered my nine year-old a seat in a car — saying it would work out fine but the seat would be without a seat belt.

What? This kid of mine always uses a booster and a seat belt (he’s only 4 foot 7 inches tall). I mean, it’s 2018 and we know seat belts have saved more than 329,715 lives between 1960 and 2012 alone — more than all other vehicle technology combined, including air bags, energy-absorbing steering assemblies, and electronic stability control. I think we take their protective gift for granted. It’s hard for me to stay quiet with the “it will be fine” mentality to one of our riskiest endeavors — riding in the car. That video up there is one of my favorite PSAs of all time…

It’s not just family protection that makes protecting children a challenge. National Highway Traffic Safety Administration (NHTSA) data show that as children get older they are less likely to want to buckle up. For example, in 2016, 262 children 8 to 12 years old were killed in crashes. Nearly half of those who died were not wearing seat belts. But wearing seat belts greatly increases the chance of surviving a crash. AND using car seats, booster seats, and staying in the back of the car until age 13 years make it even safer.

Child safety seats reduce the risk of injury by 71% to 82% and reduce the risk of death by 28% when compared to children of similar age use in seat belts. Booster seats reduce the risk of non-fatal injury in 4 to 8 year-olds by 45% compared with seat belts alone.

This stuff matters. It always sounds so preachy to talk about, and I don’t want it to, but car safety is a place we SHOULD NEVER cut prevention corners. I just don’t know how to look at the world with a, “it’ll be fine” lens. Maybe because I’ve seen so many times, mostly during my medical training, that without proper seat belts and boosters it sometimes isn’t fine. Okay. New recommendations for car seats and seatbelts out this week. Let me get us all up to speed:

Since 2011 I’ve been saying: “2 is the new 1” when it comes to car seats but now it’s more like “4 or 5 years-old may be the new 1.” Babies, toddlers, & preschoolers are safer when in seats that face the rear of the car.

Back in 2011 we got serious, encouraging parents not to turn their newly-minted one year-old forward-facing in the car — the reasons were clear – data confirmed it was much safer for toddlers to remain rear-facing in the car (and in the event of a huge slowdown or car accident as the car comes to a stop, a toddler’s relatively large head and neck are protected better with the entire back, and sides of the seat, restraining them).

That recommendation has recently changed based on re-examination of the data and the ongoing understanding that rear-facing is safer……even longer. We’re borrowing from the Scandinavians here where most children sit rear-facing all through toddlerhood and preschool. Fortunately most “convertible” or car seats designed for toddlers are built to accommodate children rear-facing well past age 2 years. Seats have weight and height guidelines and restrictions on the seat itself, so you can always check the seat and ensure it accommodates your 3 or 4 year-old facing the back.

There is no rush to move children forward-facing — in fact every transition we make as our children grow decreases the protection they get (from infant bucket seat —> convertible 5-point car seat facing back of car —> convertible 5-point car seat facing front of car —-> booster seat in backseat —-> seatbelt in back seat —-> seat belt only in front seat at age 13 years) The new American Academy of Pediatrics guideline eliminates the age-specific milestone to turn a child’s car seat around. Instead, children should ride in rear-facing car seats until they reach the height or weight limit provided by the car seat manufacturer. That might be just before starting pre-K or Kindergarten.

5 New, Clear Recommendations For Protecting Babies and Children In The Car:

  1. Infant/Babies/Toddlers: Infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for 2 years or more.
  2. Toddlers/Preschool: Once they are facing forward, children should use a forward-facing car safety seat with a harness for as long as possible, until they reach the height and weight limits for their seats. Many seats can accommodate children up to 65 pounds or more.
  3. Early School Age: When children exceed these limits, they should use a belt-positioning booster seat until the vehicle’s lap and shoulder seat belt fits properly. This is often when they have reached at least 4 feet 9 inches in height and are 8 to 12 years old.
  4. School Age: When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection.
  5. Middle-School & Beyond: All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Even if they are as tall as you and as heavy as you, they are safer in back until at least age 13.

Why Is Rear-Facing Better:

This is physics, but it’s simple physics. The worst crashes are when a car hits something from the front. Rear-facing seats protect the child’s head, spread out the force of a crash evenly across the seat, and significantly reduce the risk of injury to the head, neck, and spine. If the car crashes and baby/toddler/preschooler are facing forward their head/neck/spine is whipped forward without any support.

Use the easy “latch and tether” method to securely attach the car seat to the frame of the car whenever possible. If you must attach the seat using a seat belt, make sure the seat belt is tight (i.e. the seat belt has no slack and won’t loosen). You want the car seat to feel very secure and immovable in the car itself.

We know that by using the proper car seat, the risk of death or serious injury is lowered by more than 70%. All children younger than 13 years should be in a vehicle’s back seat. Once children reach the height or weight limit and shift to a forward-facing seat, they should use safety seats with harnesses for as long as possible, often up to 65 pounds. Once children exceed height or weight limits for those seats, they should use a belt-positioning booster seat until the lap and shoulder belts fit properly, often when the child has reached 4 feet 9 inches in height.

Booster Seats Until 4 Feet 9 Inches Tall

  • DO THIS NOW: put a mark on the wall at 4 foot nine inches from the ground. Tell your children to come and ask about getting out of a booster only when they are taller than the mark. The goal is to have the seat belt fit them properly (the booster just boosts them up so it protects them more safely). The seat belt should rest on top of thighs/pelvis, go straight across middle of chest, and cross the middle of their collar bone, avoiding their face and neck. Kids need to be able to sit back in the seat (no slumping over) when riding in the car.
  • The booster seat is critically important because it helps the seat belt (and your child!) stay in position during a crash so that the car can do its job to protect the occupants. Seat belts are only designed for adults and don’t fit properly until a child is around 4 feet 9 inches tall – most kids will reach this height sometime between 9 and 12 years of age. I also like to remind kids that when in a booster they are up higher and can see better out the windows! True…
  • Some parents mistakenly put kids into the seat belt when they aren’t big enough. Dr. Beth Ebel, a Seattle Children’s pediatrician who also researches injury prevention and cares for children at Harborview Medical Center sees these older kids admitted with serious abdominal injuries, spinal fractures, and head injuries because the seat belt doesn’t hold their torso in a crash.
  • Don’t negotiate on car safety. Dr. Ebel and I both keep extra inexpensive booster seats and ask that every kid traveling in our car use one and provide it to others driving our children. Even JUST this week my 4th-grader was complaining about his booster but there’s no negotiating here. He’s not 4 foot 9 yet. And the booster helps position the seatbelt properly.

Hope this all helps amplify your resolve to be awesome at using car seats and seat belts and waiting to turn your babies to face the front long after age 2 years. And also, watch this, a good reminder for us ALL behind a wheel:

Quick Reminder: Children Need To Play

Rounding off the summer with a somewhat obvious reminder to let our children play. This, as we bolster ourselves for the onslaught of the school year. Play remains an essential element of childhood and is good for children (of any age). Eating-vegetables-good-for-them but a lot more fun.

Summer has been a gorgeous reminder for me in how much joy I feel when my children roam and play and react and delight. I mean clutch-my-chest moments in just watching them tool around on a scooter, in the lake, or with our puppy in the backyard. Playing cards and laughing about how bad it all goes…..it’s these moments that feel most precious. A no-duh, I suppose, but each summer I’m reminded in a new way. I remember a moment in a Wisconsin lake this summer nose-to-nose with my youngest, the light silhouetting him, as a moment I want to (and plan to) hold onto forever. That tiny time in my life (lasted just seconds) so beautiful and HUGE and dear to me the memory of it almost seems to play in slow motion.

Nothing like that happened with an iPad this summer.

There’s reason not to maintain some of this summer-time play attitude all year. Play and this silliness remain relevant to raising children, and in my opinion, we gotta fight to protect it. Read full post »

What Is Dry Drowning

There was a media blitz on “dry drowning” last summer, just about this time, on a topic that is stirring up angst and worry among parents again this year. There’s good reason it makes parents nervous – drowning at baseline is a preventable tragedy that is terrifying to think on–  and it’s the leading cause of accidental death to children between age 1 to 4 years, and the second leading cause of accidental death in those between 5 and 14 years. Everyone is scared of it for good reason. But “dry drowning” (a submersion injury that happens in a different way from what most of us think about when we think about children drowning) sends people through the roof, in part because of misunderstandings. And the language, and the misleading nature to it all.

What Is “Dry Drowning?”

The term in itself is a bit confusing (and a little controversial among doctors — most emergency room doctors and pediatricians don’t want to use the term AT ALL). Pediatricians prefer and recommend referring to both dry and secondary drowning as “submersion injuries”. Drowning is drowning — but drowning, in and of itself, doesn’t mean death, it means exposure to water, by submersion, and injury from it. Technically speaking, as I understand best how parents and media talk about it, dry drowning is when a small amount of water causes spasms in the airway and the soft tissues in the airway (epiglottis, larynx) thus causing the airway to close up and make breathing very difficult. This is rare – but would happen within a few minutes of water entering the mouth and throat and being pushed back towards the airway, instigating spasm. This happens immediately after exiting the water. The spasm can be very dangerous and typically would cause sputtering or coughing or choking. This is an immediate reaction to water entering the airway. Read full post »

10 Things To Do While You Wear Orange To Support Reducing Gun Violence

Bravery — this is gonna take ongoing bravery!

Today is National Gun Violence Prevention Day and many around our country are rallying by wearing orange. Wear orange, please, but let’s remember that this is a long-term effort — to protect our children this is an everyday thing to help shape and change our culture. We must be persistent and carry today’s inspiration for orange through every day and tackle every opportunity we are presented with to reduce gun violence and tragedy. We must be brave to speak out and up about what we believe. We know #BlackLivesMatter and we know risk from gun violence isn’t the same for all of us. Children of color are at higher risk. We can work to reduce gun violence in so many ways by becoming more intolerant of injustices we see. They are everywhere and I think we are collectively learning more and more every day. This week’s news on twitter is no exception. We know school shootings go against everything we all want for our children. In addition to orange, let’s be bold. Let’s keep inventing new ways to reduce violence, suicide, tragedy, harm, and suffering from gun violence. This remains personal to me and I won’t relent.

10 Resources And Ideas To Help & Organize & Support #EndGunViolence

Read full post »

No Benzocaine For Teething Babies

Hallelujah, I’ve been saying I don’t like teething gels since 2010. This is a PSA for all parents out there trying to help soothe their teething baby. Today, the FDA came out and said avoid using over-the-counter teething products containing benzocaine. That means no teething gels like Anbesol, Baby Orajel, Cepacol, Chloraseptic, Hurricaine, Orabase, Orajel, Topex or other generic brands. The agency said “products containing the pain reliever benzocaine for the temporary relief of sore gums due to teething in infants or children should no longer be marketed and is asking companies to stop selling these products for such use. If companies do not comply, the FDA will initiate a regulatory action to remove these products from the market.”

This is great news for parents (and pediatricians who have been advising against it for years). In general, I think most pediatricians think of teething as a developmental milestone, not a condition that demands medicine. That being said, we always wanna make our babies, who may look uncomfortable, more comfortable. But the last thing we want to do is reach for something that might cause harm. Read full post »

5 Quick Things: Hot Cars, 13 Reasons Why, Marijuana Smoke, Single Sports, Co-Sleeping

I recently changed up the format of reporting I do with my local NBC affiliate station KING5 News. I’m doing more of a weekly roundup of pediatric studies, current events and newsworthy topics that I think are important for parents to know about. For those of you who aren’t able to tune in, I wanted to share a brief synopsis of what I’m covering. Let me know what you think! What topics would you want me to talk about?

1. 13 Reasons Why: Netflix released the second season of “13 Reasons Why” a popular show about a high school student’s suicide. A recent Pediatrics study that found hospitalization rates are increasing for suicide attempts and ideation (doubled between 2008-2015), so this show’s release was particularly untimely. I really appreciate the HealthyChildren.org page with strategies for parents to discuss the show with their teens. These portrayals in media matter: using Google Analytics, data found that there was a significant increase in online searches for suicide, including searches for how to kill oneself, in the days after 13 Reasons Why debuted. This increase reflected as many as 1.5 million more searches than expected, with a 26% spike in searches for the phrase “how to commit suicide.” Reminder that all teens should be screened every year for depression starting at age 12. Here’s a fantastic piece with 13 Things All Pediatricians Should Know About 13 Reasons Why but I think all parents should, too.

Read full post »

Is Co-Sleeping Safe? Do You Do It?

The short answer to the title is —- not really, and the risk varies. But I sure get why so many parents want to co-sleep despite most pediatricians urging against it.

I was up early yesterday morning listening to NPR when a story about parents’ love and desire to sleep with their babies grabbed my attention. The headline reads: “Is sleeping with your baby as dangerous as doctors say?” I mean, parents (like me) want(ed) to co-sleep and bond with their babies, of course, especially when their babies fuss and cry and especially when parents are exhausted. Every pediatrician hears and understands the parent who says something like, “By 3am I was just so tired I plopped her in bed with me after feeding and gave up on the bassinet.”

Parents ARE tired and want to make that crying, noise, and a baby’s sadness go away. The piece opened up the challenge in parents feeling judged or insecure about sharing truths with pediatricians who have strongly advised them to separate sleeping spaces. Many parents may feel that if they continue, in overwhelm, or instinct, or in love to bed-share and co-sleep, they have to keep it from their pediatrician.

The rub here is pediatricians want what is best for families and what’s best for the bond between babies and their parents. But they also want to protect babies as best they can with the evidence fueling guidelines and advice.  How we’re talking about this may miss some salient points in American family lives.

Putting babies on their back in safe sleep environments has proved so helpful for protecting babies. But the guidelines may have focused too little on the risk that comes with over-tired parents who just can’t follow the advice and the risks co-sleeping may pose particularly when a tired, working mom co-sleeps out of desperation. Sleep experts have helped me understand that sleep deprivation changes arousal and it may be riskier for an over-tired parent to co-sleep than a better rested one. Read full post »

Car Seats and Booster Seats And Your Precious Cargo While Carpooling

A friend pulled me aside last week urging me to write about car seat and seatbelt safety. His family had been involved in a rollover accident on the way home from school — literally, just turning in an intersection, as I understand it, they were plowed into by another car which caused their car to flip. No one was seriously injured, thank goodness, but the children were left dangling upside down, hanging by seat belts, until the medics arrived. Clearly they were shaken…and reminded how precious our time is on this planet — and how the most dangerous thing most of us do everyday is drive. All the children had seat belts on and all the children were in the back seat. Phew!

Thing is, just after this dad urged me to write this, I mean literally, just minutes later, we pulled away from a group of parents at pick-up and I watched an 11 year-old get into the front seat of her family’s car and drive away. My stomach dropped. Children under age 13 shouldn’t be in the front seat and goodness gracious, the irony of the timing just got me in the gut. Hard to message and write about something that I feel parents don’t want to know more about. Something about a laxity here for many people remains…seems this is advice many already feel they know (and don’t want to take).

3 reasons children shouldn’t sit it front seat until age 13 years: 1) It’s always safer to ride in the backseat (it’s also illegal to ride in front under age 13 years in WA state), 2) children under age 13 years are at increased risk for injury from airbags (designed for a 140 lb male), and 3) children’s bone development at the hips and breastbone is immature leading to increased risk of more serious injury in front seat

When it comes to infants and little children, maybe it’s different — I feel like parents are more interested in the data and reminders. Research out last week confirms what pediatricians have been recommending for years: rear-facing car seats to keep children safer in rear impact collisions. “We found that the rear-facing car seats protected the crash test dummy well when exposed to a typical rear impact,” said lead study author Julie Mansfield. If you’re hit from behind or the side or the front, we want children under 2 years of age rear-facing! Read full post »

5 Things You Should Know About Concussions

This is a post authored by J. Forrest Bennett, ARNP who works in the rehabilitation department and on the concussion team led by Dr Samuel Browd (@DrBrowd), medical director of Seattle Children’s Sports Concussion Program. Forrest has had the unique experience to care for children after concussions in the immediate time after injury and in weeks to months thereafter when symptoms are prolonged. His wisdom can help us all understand the opportunity we have to improve children’s recovery after a head injury. In this post he explains what happens to the brain cells during a concussion, what constitutes risk for concussions, and the 5 things all of us need to know about concussions. I certainly know more after reading this and suspect you will too. Please leave comments or questions if you have them. Click here to read the first post in this series. 


Soccer is the highest risk sport for school-age girls.

Soccer is the highest risk sport for school-age girls.

What Happens During A Concussion?

A concussion is a complex process affecting the brain, brought on by biomechanical forces (like a blow to the head, car crash, etc.) The force is transmitted to the head and can result in usually short-lived symptoms such as headaches, brief loss of consciousness, nausea, and/or dizziness. These symptoms are believed to be due to a temporary shift in the neurotransmitters (chemicals that allow cells to communicate) in the brain. This helps explain the symptoms associated with a time-limited injury such as a concussion.

This also explains why diagnosing and managing concussions can be frustrating for families and medical providers. Unlike a broken bone, we do not have imagining or blood tests that enable definitive diagnosis of concussion. Medical providers will sometimes order head CTs or brain MRIs to make sure that there is not a more severe injury, but the scans cannot diagnosis concussion.

Diagnosing concussion currently relies on a detailed history and physical exam. If an injury occurs when a child is playing in an organized sport, a sideline assessment should be performed to look for common post-concussive symptoms. In 2017, the guideline for sideline assessment for concussion was updated. Depending on the severity of the initial presentation, one may need to be evaluated in an emergency department to help rule out a more severe injury.
The goal is to prevent injuries, screen for potential head injuries when appropriate, and to diagnose injuries so that we can treat the symptoms and limit the impact.

How To Prevent Head Injuries

Read full post »

Sore Throat Versus Strep Throat

When you or your child has a sore throat, it can be hard to tell if it might be something that needs medical intervention, like Strep throat. Strep throat is an infection caused by group A Streptococcus (GAS). When you confirm (by throat swab in the lab) that GAS is present, your child needs 10 days of antibiotics. If the test is negative, it’s unlikely you need any Rx medical treatment! More below:

  • Sore Throat
    • Tonsillitis refers to tonsils that are inflamed. Inflamed tonsils (and even when they have white stuff on them) doesn’t necessarily mean your child needs antibiotics. If enlarged tonsils make it hard to swallow or changes the sounds when your child breaths, they need to see a pediatrician.
    • Pharyngitis refers to an inflamed throat. Most episodes of pharyngitis are caused by infections from viruses. Some are caused by other bacteria that live in the throat that aren’t as problematic as GAS and don’t require antibiotic treatment.
    • Viruses, bacteria, allergens, environmental irritants (such as cigarette smoke), and chronic postnasal drip can all cause a sore throat. Most tonsillitis & pharyngitis will typically resolve on their own without prescription treatment.
    • Try acetaminophen or ibuprofen for pain, throat lozenges, warm beverages, gargling salt water and get lots of rest. In time, sore throats typically improve in a few days.
  • Strep throat is an infection caused by a specific type of bacteria, Streptococcus. Infections from the bacteria can be minor or severe. When your child has Strep throat, their tonsils are usually very inflamed, they likely have a fever and swollen lymph nodes in the front of the neck, a BAD sore throat, and sometimes a headache. Many children complain of lots of pain with swallowing. Strep throat symptoms typically come in isolation from other “cold symptoms.” With typical strep, most children do not have cough, runny nose or hoarseness (changes in your voice that makes it sound breathy, raspy, or strained). No one can diagnose strep throat just by looking at your throat. Instead, healthcare professionals use two tests to see if group A Strep bacteria are causing a sore throat. A “rapid strep test” involves swabbing your throat and gives results quickly, usually in about 15-20 minutes. The test is accurate about 95% of the time meaning only 1 in 20 people (5%) who have a negative test actually may have the infection. If the rapid test is positive, your doctor or provider will prescribe antibiotics. If the test is negative, your healthcare professional may likely send the swab for a full throat culture (to catch the 5% that falsely didn’t show an infection). A throat culture involves sending a throat swab to a lab for 1-2 days to see if bacteria grow from the sample. If it turns positive, then your child should be treated with an antibiotic for 10 days.

Great information from the American Academy of Pediatrics on the differences between a sore throat and strep.