Working Across Geographies to Share Ideas and Bring the Best Care to Patients


You may have heard the news that the American Academy of Pediatrics (AAP) has revised its 2011 guidelines about keeping children rear-facing in car seats until the age of 2 years and 30 pounds. Actually, the former recommendation continued with: “or until they exceed the height or weight limit for the car seat.” The new revision doesn’t change much except for removing the 2 years and 30 pounds criteria.

The new AAP Guidance for Families

  • Children should ride in a rear-facing car safety seat as long as possible, up to the limits of their car safety seat. This will include virtually all children under 2 years of age and most children up to age 4. 
  • Once they have been turned around, children should remain in a forward-facing car safety seat up to that seat's weight and length limits. Most seats can accommodate children up to 60 pounds or more. 
  • When they exceed these limits, child passengers should ride in a belt-positioning booster seat until they can use a seat belt that fits correctly. 
  • Once they exceed the booster limits and are large enough to use the vehicle seat belt alone, they should always use a lap and shoulder belt
  • All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. 

Why the change? 

The 2011 guidelines were based on a study done in 2007 and according to Dr. Benjamin Hoffman, Chair of the American Academy of Pediatrics Council on Injury, Violence and Poison Prevention Executive Committee, "We just don't have a large enough set of data to determine with certainty at what age it is safest to turn children to be forward-facing." Therefore, the specific age and weight criteria have been removed. 

Why is rear-facing better?

  1. "Rear-facing is still the safest way for children to ride," says Dr. Hoffman. 
  2. Every transition actually reduces the amount of protection a child has in the event of a crash. According to Dr. Hoffman and his colleagues at the AAP, parents really shouldn't rush transitioning kids out of rear-facing seats - and later, into boosters. 
  3. A rear-facing car seat will absorb most of the crash forces and support the head, neck and spine. When children ride forward-facing, their heads - which for toddlers are disproportionately large and heavy - are thrown forward, possibly resulting in spine and head injuries. 
  4. Many car seats manufacturers have created seats that allow children to remain rear-facing until they weigh 40 to 50 pounds. Even many infant-only seats have a higher weight limit to 35 or 40 pounds. 
  5. Evidence does not support that children will suffer leg and foot injuries if their feet touch the seat. There are no known harmful effects of riding read-facing longer, while the benefits of doing so have been observed for years. Children have many ways of making themselves comfortable when facing the rear and can ride safely that way, as long as they have not reached the weight or height limit for rear-facing in their seat. For many kids, this could be well past two years. In Sweden, children routinely ride rear-facing until the age of four. 

Safely transporting children has come a long way from the days when would put a baby front-facing at age 1 and 20 pounds. Keep your child rear-facing for as long as their seat allows and check the label on your car seat to make sure your child fits the weight and height guidelines and that you are using the seat correctly.

Primary Children's Hospital offers free car seat checks by our trained and certified car seat technicians to make sure your child is riding as safely as possible. If you'd like to make an appointment for a car seat check, or if you have questions or concerns about car seats, simply call us at 801-662-6583 .

In the Patient's Best Interest

The Musculoskeletal Clinical Program is bringing the various members of their teams into conversations with patients when it comes their course of treatment. This gives patients options—options other than surgery, which can be invasive, expensive, risky, and maybe even not the right course of action. Involving other members such as physical therapists in initial conversations with patients allows our patients to have generous time up front to best understand all the options and what may be most appropriate for their individual treatment plan. Surgeons have surgeon mentalities and may be predisposed to recommend surgery first, Dr. West says, which may not be in the best interest of the patient. However, physical therapy, nonsteroidal anti-inflammatory drugs, or other approaches, might.

According to Dr. Krakovitz, “We need to continue to educate to this model…showing how this improves the value to the patient, how we can take a patient who thinks they need to undergo a scary surgical procedure, and in the end, they may still require that surgery but [the conversation] gets them to a point where they’re ready for it and they know they’ve exhausted all their options. It takes education, it’s really starting with a thought leader like Dr. West, to get us to that point.”

Taking Time and Connecting Across Distances

Along with bringing clinicians involved in the specialty into the conversation early, at the most appropriate time for patients, Dr. West and his Clinical Program are also better aligning teams from within by holding weekly, highly organized, in-person and telepresence meetings. The meetings have been successful, with clinicians attending consistently. For these 45 minutes each week, the clinicians aren’t seeing patients, they’re not doing surgery, and they’re not making money. In essence they’re volunteering their time. So what is the value that these meetings bring?

Clinicians within the Musculoskeletal Clinical Program are participating, contributing, and connecting across great distances. “Clinicians have a latent hunger for learning, to be recognized by and to have dialogue with their peers,” says Dr. West.

“When they leave their training they become practitioners in isolation,” he says. For example, the Clinical Program had a goal last year to prevent venous thromboembolisms among their surgical patients. To identify what was being done already to prevent blood clots and the serious complication of pulmonary embolism, they asked 30 to 40 arthroplasty physicians what they were doing and got 30 to 40 different answers. “Over the course of the year,” says Dr. West, “through repeated touches on the subject at the weekly meetings we came to a consensus of what that care should be. That has not been built into the iCentra Power Plans yet, but just socializing the right care needed has reduced the incidence of pulmonary embolism dramatically in a very short period of time.”

Dr. West also provided an example of a total joint replacement surgeon in a rural hospital setting who, prompted by these weekly meetings, worked with the Clinical Program to set up a tour to see the care processes being followed in other parts of the Intermountain system. The physician shared with Dr. West that he got to know his fellow surgeons better, but even more valuable to the field trip was his ability to learn a better way of doing things and his eagerness to bring this to his own community.

“Our respect as an orthopedic group grows for each other with these meetings—we feel more comfortable having people we don’t work next to, on the peripheries of our system, taking care of patients rather than any past inclinations to send patients from all over, to Salt Lake,” says Dr. West.

Learn more about the Musculoskeletal Clinical Program’s new model of specialty alignment for care and their future continuous improvement plans by listening to the podcast here.