22 March 2011

Unhealthful News 81 - Pediatrics gets one right; the world moves backwards

The journal Pediatrics is notorious for publishing alarmist junk-science claims in the form of pseudo-research papers.  They are also the mouthpiece for the American Academy of Pediatrics, an organization that is notorious for making policy declarations without actually doing any policy analysis.  But their latest recommendation that has been all over the headlines seems to be reasonable, though that is not for lack of trying to do a bad analysis.

The latest dictate from the AAP is that babies should ride in rear-facing car seats until they exceed the height or weight limit for those seats, rather than switching them to forward as soon as it is possible or legal, often their first birthday.  They based this recommendation on evidence that being in a rear-facing seat remains considerably safer for these somewhat older children.  This should really come as no surprise, and if anything this observation is disturbingly late in coming, since (a) rear facing is fairly obviously safer, all else equal (and you are not operating the vehicle), for anyone in any vehicle due to the physics of the transport, since dangerous deceleration happens much more often than dangerous acceleration, (b) there has been epidemiologic evidence for a very long time, and (c) this was already the standard in other countries. 

So the advice turns out to be good.  Not so good is the message that AAP apparently included in their press packet (it was claimed in too many news reports to be coincidence) that the reason that parents turn their children around so early is that it is some kind of first-birthday rite of passage.  While perhaps a few parents feel strongly about this, the car-seat-reversal-as-circumcision seems like a pretty dumb story.  The alternative explanation offered in the news is that parents feel the kids are bored facing backward.  Apparently the physicians who dictate AAP's policy statements are clueless about the experiences of parents of only-children who take care of the kid alone and really hate having to leave the little guy alone in the back, where you cannot see if he is distressed, breathing, etc., for substantial periods of time for a year – and now more – of his life.  And it is not just boring, it is alone.  If the authors had made an effort to understand this it should not have changed the recommendation, but perhaps they would have done something useful, like suggest one of those cute mirrors that let the driver see the baby, and play music for him at the touch of the button.  (But only glance back occasionally or next year's headlines will be:  Is watching your baby in the mirror more dangerous than texting while driving?)

The point is that they are pretending-away the costs.  This is typical AAP behavior and the classic error made by those who presume to offer policy prescriptions but do not understand what policy prescriptions should be based on:  They see that the policy has one benefit and so they recommend it.  Perhaps you noticed that I wrote they based the recommendation on the evidence about greater safety, full stop.  But every policy has one benefit; the question is do the total benefits outweigh the costs.  To figure that out, it is necessary to quantify the benefits (they actually made an estimate in this case, which is better than they usually do) and costs, and see if the former outweighs the latter.  It pretty clearly does in this case, but that does not excuse them for making a joke of the cost (which is also pretty common behavior for AAP – not only do they ignore the costs, but they dismiss or even  anyone who might worry about them).  This is, after all, the same AAP that has such a long list of activities that a pediatrician is supposed to perform in a well-child visit that it would take roughly all day to do all of them.  Not only are they unaware of the basics of policy analysis and the experiences of parents, but they apparently cannot even figure out that those in the group they represent have about six minutes per patient, not six hours.

This is what I mean when I say that they got this one right, but not for lack of trying to get it wrong.  A similar "analysis" would also lead to the conclusion that all babies should have to be in backward facing seats in planes, which is a terrible idea.

But the gang from Pediatrics did manage to find something dumb to say, even while offering good lifesaving advice.  They insisted that the infant car seats should not be used outside the car because they are often set somewhere such that they fall, and thereby injure 8000 kids a year.  Yes, that's right, if you need to pop into a store for a minute or give your infant a place to sit in a restaurant you should just… um… well, leave him at home.  (That is actually not bad advice – it is much safer to leave the kid at home while you run an errand for 20 minutes rather than exposing her to the much more dangerous experience of being in the car.  The problem is that if something happens to the kid at home, you will go to prison, while if you cause her to be injured by taking her for a ride, well, tragic accidents happen.)

So instead of using this nice solid car seat as a temporary carrier and storage place, you should juggle the baby in and out of it extra times, and carry her in your arms while shopping or eating, or just walking into the house.  Yeah, what could go wrong there?  It is classic Pediatrics:  The policy has a benefit (avoiding injuries from falling while in a car seat), and so long as you ignore the costs, (substantial hassle in many cases, and presumably even more falls, but now without armor) it looks great.  I suspect a closer look would reveal that most of those 8000 involve serious bad judgment that is probably not caused or exacerbated by the car seat being used as a hand carrier.

But I do not want to distract from the real error here, which might have been lost in the above.  This was not based on any new information (they cited a study from 2007 and Swedish population data that has existed for a while).  The basis for making this recommendation has existed for years, and babies have died because of the delay in communicating it.  It is bad enough when people who make behavioral recommendations pay attention only to safety and ignore all other human concerns, but at least they should try keep all their errors in the direction of being too aggressive rather than dropping the ball for years.

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