Reference list

While both rearward-facing and forward-facing child restraint systems (CRSs) provide significant safety benefits compared to an unrestrained vehicle occupant, the following references support the claim that rearward-facing CRSs are even safer than forward-facing seats and should be the primary option for young children. Some studies have additional comments describing the content of the study. In addition, some studies have commented on potential issues with airbag interactions for small children and shield systems, this has been highlighted by comments/quotes.  

As noted by Tingvall (1987) in his PhD thesis: “The outcome of an accident must still be considered as stochastic and not deterministic, as it is still impossible to control all factors influencing the outcome. Quantitative studies of real life accidents and injuries are therefore important.”. The following references span 50+ years of research on human anatomy, epidemiology, accident reconstruction, crash tests with dummies, and numerical analysis by various independent researchers and agencies. This highlights the breadth of research supporting the rearward-facing claim, also when including real-world variability from actual traffic accidents over multiple decades and not just a controlled crash test scenario.  

1. Aldman (1964). A Protective Seat for Children – Experiments with a Safety Seat for Children between One and Six. In: Proceedings from the Eight Stapp Car Crash Conference, Detroit Michigan, USA, https://doi.org/10.4271/640855. 

2. Arbogast et al. (2002). Injuries to Children in Forward Facing Child Restraints. 
   Comment: In-depth crash investigation study to identify the mechanisms of injury in forward facing child restraints. In: Annual Proceedings from the Association for the Advancement of Automotive Medicine, Vol. 46, p. 213-230. 
   Quote: “The occurrence of head and neck injuries in these children provides supporting data to suggest that an extension of the current recommendation to keep children rear facing beyond 1 year of age may be appropriate. […] This result is supported from data from Sweden which shows that keeping children rear facing up to age three or four years reduces all types of serious injuries not just those to the head and neck.”. 

3. Benedetti et al. (2019). Factors affecting child injury risk in motor-vehicle crashes. Stapp Car Crash Journal, Vol. 63. 
   Comment: This study looked at more recent US crash data (year 2010-2015) to evaluate if this supports previous recommendations on child restraint usage. They conclude that the results support current best practice recommendations to use each stage of child restraint (rear-facing CRS, forward-facing harness CRS, belt positioning booster seat, lap and shoulder belt) as long as possible before switching to the next step.  

4. Belwadi et al. (2019). Responses of the Scaled Pediatric Human Body Model in the Rear- and Forward-Facing Child Seats in Simulated Frontal Motor Vehicle Crashes. Short Communication from the AAAM 63^rd Annual Scientific Conference, Traffic Injury Prevention, Vol. 20, No. S2, s143-144. 
   Comment: Simulation study with the 6-year-old PIPER HBM scaled to create anthropometric models of the 18-, 24-, 30-, 42-, and 48-mont-old child in a frontal impact. 
   Quote: “The neck forces were reduced by 83%-90% and the neck moments were reduced by 63%-85% in the rear-facing models compared to their respective forward-facing configurations. The reduction in head injury criterion (HIC36) for rear-facing models ranged from 14% to 51%. The neck injury criterion (Nij) for all forward-facing models was 6 to 9 times the values in their rear-facing counterparts.”. 
   Quote: “The results of these controlled simulations show the potential benefit in frontal crashes of keeping children rear-facing longer. There is a clear benefit to the head-neck complex due to the support provided by the seatback of the CRS resulting in lower neck forces and moments when the model is simulated in the rear-facing configuration compared to their respective forward-facing counterparts.”. 

5. Carlsson et al. (1991). Rearward-facing child seats—The safest car restraint for children? Accident Analysis and Prevention, Vol. 23, Issues 2-3. 

6. Carlsson et al. (2013). Review of Child Car Occupant Fatalities in Sweden During Six Decades. In: Proceedings of the International Conference on the Biomechanics of Impacts (IRCOBI), pp. 868-881.  
   Comment: A study of all fatally injured 0–14-year-old car occupants in Sweden during 1956-2011. 
   Conclusion: “In total, only 15 of the fatally injured children were restrained in rearward‐facing CRSs. Four cases occurred in frontal impacts (all involving severe crashes with a heavy vehicle), and zero cases in rear‐end impacts. The low relative numbers and the situations in which the few cases occurred confirm that rearward‐facing CRSs are extraordinarily safe and robust protection systems.”. 

7. Durbin et al. (2018). Child Passenger Safety. American Academy of Pediatrics. 
   Comment: This is the American Academy of Pediatrics “Policy Statement” on child passenger safety, which was reaffirmed 2025. It states that evidence-based recommendations for the best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children is to use a rear-facing car seat for as long as possible and only switch to a forward-facing seat when they outgrow their rear-facing seat, typically through at least 4 years of age. 
   Quote: “Rear-facing CSSs provide optimal support to the head and spine in the event of a crash.”. 

8. Fuchs et al. (1989). Cervical Spine Fractures Sustained by Young Children in Forward-Facing Car Seats. Pediatrics 84(2), pp: 348-354. 

9. Giovannini et al. (2024). Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation. International Journal of Legal Medicine, Vol. 138, pp. 1329-1341. 
   Comment: This is a systematic review on forensic medicine about traffic accidents involving pediatric passengers from 1970 to 2023. A total of 69 studies satisfied the inclusion criteria and were examined and discussed. 
   Quote: “For infants, forward-facing car seat are associated with a higher incidence of skull fractures and intracranial damage [9]. Conversely, rear-facing car safety seats offer optimal support to the head and spine during a crash, as forces are directed from the car safety seat’s back to the infant’s back, which represents their strongest body surface [100].”. 
   Quote: “The improper use of child car seat systems in the front seat, particularly combined with airbags, favours specific injury patterns, explained by the mechanisms associated with airbag trauma [7].”. 
   Quote: “For older children, braking before impact causes them to shift forward, placing them closer to the dashboard. When the airbag deploys, it impacts the face and frontal cranium, including violent hyperextension of the cervical spine and subsequent lesions [32]. The lower body mass of children renders them more vulnerable to minor shifts in body position during airbag deployment, resulting in face thermal lesions, abrasions, facial bone fractures, and, in extreme cases, occipitoatlantoaxial disarticulation [31, 34, 39].”. 
   Quote: “In infancy, the cervical spine is the neck region most frequently involved in motor vehicle accidents. Children are particularly vulnerable to cervical spine traumatisms in frontal crashes, in which spine hyperflexion distraction may lead to fractures of cervical vertebrae and brainstem damage [52, 80].”. 
   Quote: “If the child retained in the car seat is seated in the front passenger seat, airbag deployment during an accident can cause hyperextension of the cervical spine due to facial impact [34, 39, 80].”. 
   Quote: “If children were secured using forward-facing child car seat systems, injuries below the knee, specifically affecting the tibia and fibula, are notably common.”. 
   Quote: “In frontal motor vehicle crashes, pediatric models in rear-facing configurations generally show lower injury numbers than those in forward configurations, especially recommended up to at least 2 or 4 years of age. This is associated with a better support to the neck and the head, preventing rotational motion of the head [85, 91].”. 

10. Isaksson-Hellman et al. (1997). Trends and Effects of Child Restraint Systems Based on Volvo’s Swedish Accident Database. SAE 973299. Child Occupant Protection 2^nd Symposium. Society of Automotive Engineers, Warrendale, PA, pp. 43-54.  
    Comment: An analysis of Volvo’s own traffic accident material. The crashes occurred in Sweden between the years 1976 and 1996, a total of 26,000 crashes involving 46,000 occupants were analyzed. A total of 421 occupants utilized a rearward-facing CRS were included in the sample. Zero fatalities were recorded for the rearward-facing group and almost no severe injuries (the only AIS2+ injuries were two leg fractures and one minor brain concussion from a severe rear end impact where the child had been ejected from the CRS).  

11. Jakobsson (2005). Safety for the Growing Child – Experiences from Sweden Accident Data. In: Proceedings from the 19^th International Technical Conference on the Enhanced Safety of Vehicles, Washington, DC, USA. 

12. Jakobsson (2017). Rearward Facing Child Seats – Past, Present and Future. In: Proceedings from Protection of Children in Cars, Munich, Germany. 
    Comment: Article summarizing the history of rearward facing child seats. It motivates why rearward-facing is safer not only in the pure frontal scenario but also for oblique and side impacts. It also summarizes results from both physical crash tests and from real accident data that supports rearward-facing as the safer alternative. 
    Quote: “Nowadays, most child safety experts agree that rearward facing mode is the safest alternative for infants and provide essential protection to toddlers up to 3-4 years. The argument against rearward facing for this group are not due to safety but due to ease of use, lack of space and other comfort and usability related aspects.”. 

13. Johannsen et al. (2013). Analysis of the Performance of Different Architectures of Forward Facing CRS with Integral Restraint System. In: Proceedings of the 23^rd International Technical Conference on the Enhanced Safety of Vehicles (ESV), Seoul, South Korea. 
    Comment: This study does not compare rearward-facing to forward-facing, only the performance of 5-point integral harness systems with shield systems in frontal impacts. 
    Quote: “While shield systems are advertised to protect the neck better than 5-point harness systems, this is overall not supported by the test results, especially for neck moments which appear to be higher with shield systems for most of the tests. However, for the long duration ADAC pulse shield systems show clearly lower neck loadings.”. 
    Quote: “Dummy readings are also considerably higher for thorax and abdomen for shield systems than 5 point-harness systems. Based on the limited accident data available, this seems associated with more frequent injury to these regions with shields.”. 
    Quote: “Overall, the results from the current study do not clearly indicate a benefit of shields for the head and neck. However, they raise questions about possible risks to the thorax and the abdomen.”. 

14. Kamrén et al. (1993). The Protective Effects of Rearward Facing CRS: An Overview of Possibilities and Problems Associated with Child Restraints for Children Aged 0-3 Years. Child Occupant Protection Symposium, Warrendale, Pennsylvania, USA. 

15. Kirk et al. (2011). Child Car Passenger Fatalities – European Figures and In-Depth Study. In: Proceedings of the 9^th International Conference on Protection of Children in Cars, Munich, Germany. 
    Comment: Paper reporting on work undertaken in the EC CASPER (Child Advanced Safety Project for European Roads) project and the CASIMIR (Child Accident Study Investigating Mortal Incident on the Road) project regarding fatality studies. 
    Quote: “The under 1 year old peak can be attributed to a switch from rearward facing to forward facing restraint systems too early in France.”. 

16. Klingegård et al. (2025). Child Restraint System (CRS) usage in fatal car crashes in Sweden and the potential of rear-facing CRS to influence injury outcomes. In: Protection of Children in Cars Conference, Munich, Germany. 
    Comment: A case-by-case study of all fatally injured child car occupants (0-6 years) in Sweden during 1992-2024. The data included 99 fatally injured children in 83 cars. 
    Quote: “The analysis indicates that up to 48% of fatally injured children aged 0–3 years likely could have survived if they had been restrained in a rear-facing CRS. As many as 12 of the 19 children (63%) under the age of four that were using a forward-facing CRS could have survived if the child had been using a rear-facing CRS. This reinforces the well-documented advantages of rear-facing orientation, which provides superior protection for the head, neck, and spine in frontal impacts, the most common and severe crash type. The protective principles of the seat shell provide optimal support for the child’s vulnerable neck, not only in frontal and side impacts but also in more complex crash scenarios such as rollovers and run-off-road incidents. It is also more forgiving for misuse, such as slack of harness and attachments [8].”. 

17. Klinich et al. (2012). Crash Protection for Child Passengers: Rationale for Best Practice. UMTRI Research Review, Vol. 43, No. 1.  
    Comment: This is an updated version of the original publication by Weber (2000). 

18. Lesire et al. (2013). Safety Benefits of the New ECE Regulation for the Homologation of CRS – An Estimation by the EC CASPER Project Consortium. In: Proceedings from the 23^rd International Technical Conference on the Enhanced Safety of Vehicles (ESV), Seoul, South Korea. 
    Comment: Paper from the Informal Group of GRSP tasked with developing a new regulation for the homologation of CRS, assigned by the United Nations Economic Commission for Europe (UNECE). 
    Quote: “It is obvious that children with an age of 1 year old are of greatest risk [of being killed as a car occupant] in Germany while this peak is not visible in Sweden. It is expected that this peak results from too early change from rear facing to forward facing CRS in Germany.”. 
    Quote: “An early change increases the possibility of the anatomical aspects above leading to injury, particularly in frontal impacts, […]. It is therefore important to encourage parents to keep children rearward facing as long as practically possible.”. 

19. McMurry et al. (2017) Rear-facing versus forward-facing child restraints: An updated assessment. Injury Prevention, 24(1):55-59. 

20. National Highway Traffic Safety Administration (NHTSA) – Car Seat Recommendations for Children.  
    Comment: Recommendation to “Keep your child rear-facing for as long as possible” by the main traffic safety agency in the USA. 

21. Planath et al. (1992). Synthesis of Data Towards Neck Protection Criteria for Children. In: Proceedings of the International Conference on the Biomechanics of Impact (IRCOBI), Verona, Italy, pp. 155-166. 

22. Sherwood et al. (2003). Factors Leading to Crash Fatalities to Children in Child Restraints. In: Annual Proceedings from the Association for the Advancement of Automotive Medicine (AAAM). 
    Quote: “Some of the fatal head and/or neck injuries may have been due to inertia. […] Consideration should be given to keeping children in rear-facing restraints longer than their first birthday to help prevent such injuries in frontal crashes.”. 
    Quote: “Seven child fatalities (8 percent) occurred in rollover crashes. Three crashes involved ejection of children seated in restraints with a chield and thee-point harness (two tray shields, one T-shield); none involved five-point harnesses.”. 

23. Sherwood and Crandall (2007). Frontal sled tests comparing rear and forward facing child restraints with 1-3 year old dummies. In: Annual Proceedings from the Association for the Advancement of Automotive Medicine (AAAM). 

24. Stalnaker (1993). Spinal Cord Injuries to Children in Real World Accidents. SAE 933100. Child Occupant Protection Symposium, Warrendale, Pennsylvania, USA.  

25. Tarrière (1995). Children are not miniature adults. In: Proceedings of the International Conference on the Biomechanics of Impacts (IRCOBI), pp. 15-27. 
    Comment: This paper goes through the arguments for rearward-facing restraint design for ages 0-4-years-old from an anatomical and biomechanical perspective. 

26. Tingvall (1987). Children in Cars – Some Aspects of the Safety of Children as Car Passengers in Road Traffic Accidents. Acta Paediatrica Scandinavia Supplement 337. PhD Thesis. 
    Conclusion: “The use of child restraints was effective in reducing injuries especially when rearward facing restraints were used.” 
    Recommendation: “Rearward-facing child restraints should be used for as many as possible of the children.”  

27. Tushak et al. (2019). Responses of the Scaled Infant Human Body Model in Simulated Frontal Motor Vehicle Crashes. Paper Number: 19-0142-O. In: Proceedings from the 26^th International Technical Conference on the Enhanced Safety of Vehicles (ESV), Eindhoven, Netherlands. 
    Comment: Simulation study with the PIPER HBM scaled to a 18MO, 24MO, 30MO, and 36MO pediatric model tested in frontal impacts on both the FMVSS No. 213 test bench and a 2012 Toyota Camry vehicle seat. Rearward-facing was consistently found to show lower injury values for the head, neck, and chest compared to the forward-facing configuration. 

28. Weber (2000). Crash Protection for Child Passengers. UMTRI Research Review, Vol. 31, No. 3. 
    Comment: A review of best practices for child passenger protection which argues for the superior safety performance of rear-facing child seats for young children. It also comments on the “significant advantage” of belt-based restraint systems over airbag systems.  
    Quote: “Despite the potential for belt-induced injuries, belt-based restraint systems have significant advantages over airbag systems. They offer protection in a variety of crash directions, including rollovers, and throughout the course of multiple impacts. Moreover, the force on the occupant is proportional to the mass of the occupant. For example, a man weighing 80 kg will experience a much greater load into the belts on his chest and pelvis than a child weighing only 20 kg. Even though the child’s bony structure and connective tissue may be weaker than the adult’s, the child’s weight is so much less that the injury potential from contact with belts or other static surfaces is less. Current generation airbags, on the other hand, generate the same amount of deployment force and resistance to deflation regardless of occupant size or proximity to the airbag. This puts children and other small occupants at much greater risk of injury than large, high-mass occupants and is among the reasons children should not ride in seats with frontal-impact airbags.”.