Pediatric Org’s Bicycle Recommendations Explained, in Terrifying Detail

There’s nothing quite like listening to a preeminent expert in pediatric injury prevention telling you you’re taking unnecessary risks with your child’s life.

Dangerous! Photo: Doug Gordon

That more or less sums up my conversation yesterday with Dr. Phyllis Agran, who has authored and consulted on many American Academy of Pediatrics (AAP) policies relating to childhood injury and trauma prevention. I was asking her about the AAP’s recommendations on bicycling with kids.

“It’s extremely risky,” Dr. Agran told me. “If you’re hit by a car, there’s a good probability — if you look at the weight of you, your bicycle and your infant and you look at the weight of a car — there’s a high probability that you and your child would be killed.”

“It’s basic common sense,” she said. “It’s physics: mass times acceleration.”

While I worked the lump out of my throat, she went on, “I personally would not ride a bike with a child in it on the street. I would be very frightened that someone texting, someone on a cell phone, someone not coming to a full stop, someone distracted, someone cutting into my lane would kill me and my child.”

At the same time, Agran was clear about the risks of driving in a car with infants. She said that although rear-facing infant car seats “are very safe,” even properly restrained infants can die in a car crash “because they’re fragile.”

“And you’re getting into biomechanics and shearing forces and all kinds of things that make them more fragile to a mild impact,” she said.

Agran’s comment was intended to underscore how exponentially more dangerous it is to have an infant on a bike. But it also highlighted the fact that motor vehicle crashes are the leading cause of death for children, and yet AAP doesn’t even bother telling parents not to drive with their kids. It issues guidance to make an unsafe practice as safe as possible. And yet, it simply dismisses the idea of urban bicycling with small children.

I suppose I could just drive everywhere instead of biking with my 21-month-old daughter Luna. But then I’d be one more car on the road, menacing people making healthier transportation decisions, hastening climate change, spending money I’d rather save for Luna’s education, and making my city less livable. I feel good about showing Luna the world outside of a car. She calls out “wheee!” when we pass the swings at the park and “wow-wow!” when we pass a dog. She’s learning that there are lots of healthier ways to get around than an automobile. Despite the panic I feel listening to Dr. Agran talk about the dangers of cycling with children, I still believe I’m making the right decision.

Dangerous! Photo: Hilda Cohen

AAP’s guidance on bicycling boils down to this: Make kids wear a helmet. Ride “in parks, on bike paths, or on quiet streets.” Don’t put a kid under 12 months old on a bike under any circumstance. Bicycle-towed child trailers are safer than bike-mounted seats.

These recommendations don’t make much sense in an urban environment. Helmets, sure. But there’s no park I can ride in to get Luna all the way to daycare. There is a bike lane, but not protected from traffic. And for my money, rear-mounted bike seats are safer than trailers in a high-traffic setting. I didn’t find it in any publicly available literature, but Agran sent me some AAP guidance acknowledging that trailers shouldn’t be used on the roadway because they “may not be seen by motorists,” but their advice for parents biking on the road is just that “if you must carry your child on a bike,” put them on a rear bike seat and don’t do it until they’re a year old — old enough that their necks can support a bike helmet. I haven’t seen any discussion of baby seats that go behind the handlebars.

Urban biking parents don’t get any help from the country’s foremost pediatric organization on issues that pertain to their experience. When I asked Agran if they’d looked into the safety of putting a car seat into a bike trailer, as some parents do with children far younger than 12 months, she said she wasn’t aware that they had. Getting an explanation on AAP’s age minimum requires a lot of digging, and is the subject of a lot of conjecture in the bike community. Though creative parents have come up with myriad ways to mitigate the risk of crashes and excessive vibrations, there’s no one to ask for advice on that. Your average pediatrician doesn’t know much about bikes and your average bike shop employee doesn’t know much about babies.

In Europe, all kinds of innovative baby seats are available that support fragile infants, like the Chariot infant sling that suspends like a hammock inside a bike seat or trailer, letting the child swing delicately instead of absorbing bumps. But notice that even this advertisement — with the headline, “Chariot Infant Swing for Baby Bike Trailers” — warns, “not for use while cycling.” Pity the poor parent who has to figure all this out for himself!

Agran herself says that when she put her son — now 43 years old — on the back of a bike, she worried about him getting his feet caught in the spokes. “I’m sure [bike seats] are a lot better now and I know they have foot guards to minimize them getting their feet caught in the spokes,” she said. “When I think about it now, that’s all we had available — god, I wouldn’t do that nowadays.”

Dangerous! Photo: Michelle Rushing

AAP has, to their credit, issued guidance on the built environment, recommending changes to create streets that are “conducive to more walking and biking among children.” In an effort to reduce rates of childhood obesity, the organization encourages “environment modification that addresses risks associated with automobile traffic.”

That includes compact, mixed-use development and street grids that promote connectivity. They recommend street design interventions to calm traffic and create space for pedestrians. But the organization hasn’t come out explicitly in support of things like protected bike lanes and other infrastructure that makes healthy, non-motorized transportation a safe option for young people.

Agran said they encourage infill school siting where most kids can walk to school without crossing major streets. They also encourage health professionals to serve as role models in their community, using public transportation and non-motorized modes to reduce air pollution, which is a health hazard to children.

And AAP supports Safe Routes to School, though most of their guidance on school transportation safety focuses on school buses and driving with parents. Perhaps it’s because they’re very wary of the idea of kids walking or biking without adult supervision. AAP recommends that kids not walk alone until the age of 10. Dr. Agran emphasizes that there are about 20 steps involved with learning just to cross the street safely and biking adds another skill set on top of that. “Can they pay attention to everything, and at what age and what kind of streets are these, are these large arterials, are they small streets, how fast is the traffic going?”

Agran says in her community of Orange, California, at least, more kids are killed on bikes than in cars. “I don’t even remember the last time a child was killed in a car crash, whereas we’ve had a number of bicyclists,” she said. Nationally, between 1999 and 2010, 37,410 children 19 and under were killed in car crashes, compared to 1,710 killed on bicycles.

“Get the cars off the street!” Agran said toward the end of our conversation. “Get everybody to walk to school, get traffic-free streets — they’ve done that in some communities, ‘no cars on this street.’”

Now there’s a solution I can get behind.

77 thoughts on Pediatric Org’s Bicycle Recommendations Explained, in Terrifying Detail

  1. Declaring the discussion to have ended isn’t taking any bikes off the roads and streets, Bob. You’re tilting at ceiling fans.

    Telling people to give up because they’re the underdog doesn’t have a good record of making them give up.

  2. I hate this idea that permeates our culture that cycling is inherently dangerous. It isn’t. I suppose that one could stay at home, never leaving the house, but that is no way to live. Notably, this Dr. lives in Orange County. Come to Mpls, Dr. and get some perspective.

  3. Sure, take a look at Chapter 4 (People) beginning on page 89 of the report for the tables that break down injuries and deaths by age and type of crash (vehicle, bike, pedestrian, etc.). I had to do a little extra number crunching to get the rates per 100,000 for vehicle crashes, but the data is all there.

    NHTSA puts out this data every year, so you can check out previous years on their site as well. I looked at 2009 and the numbers are very similar.

  4. This made me so happy. My 13 month old, who rides in a front mounted bobike seat with a windshield, LOVES watching it with me – indeed, she dances 🙂
    Thank you for making me smile after reading such a heartbreakingly sad interview.

  5. You don’t really need to account for the higher number of kids in cars because the data you gave is per 100,000 – and it’s been shown over and over that as more people cycle the rate of accidents goes down, not up.

    Likewise, per mile data is equally meaningless. Lots of people will ride with their kids a mile to soccer practice but hardly anyone is going to ride 10 miles to the mall and certainly no one is going to ride 30 miles to grandma’s house every other weekend.

  6. Katie, thanks for picking the under-5s out of the table data and linking it to seats/trailer use. One big caveat to your interpretation I feel is that the denominator of 100,000 is for total population in the category, not for users of that particular transportation mode. So five out of the 20 million U.S. under-5s died in bicycle crashes (table 102), and 278 of the 20 million U.S. under-5s died as vehicle occupants (69).

    Using the land-use and speed-limit table (67) to identify the fraction of fatal crashes at less than 45 mph in urban areas (i.e., non-highway driving), I got 16%. If I assume that this fraction is valid for the preschoolers as well, that gives me an estimate of 45 under-5s dead in vehicle crashes on city streets, the same kind of streets people would be biking on.

    Even living in car-light New York City, I don’t see so many kids on bikes, certainly not as many as one kid on a bike per every nine kids in cars. It’s my conclusion therefore that under-5 bicycle riders are overrepresented in the fatality statistics.

  7. Deaths/injuries per trip would probably be a better measurement, but it’s hard to get good trip data, we just don’t count bikes/peds as much…

  8. I would actually assume a higher percentage of young kids killed in cars on local streets, as I imagine that’s where they’re mainly being driven. But, you’re right, we don’t really have all the data we need to do anything besides make educated assumptions. Still, taking a step back, 5 kids out of 20 million? Zero would be better, but I wouldn’t characterize that as extremely dangerous.

  9. Not even a mention of an infant seat inside of a bakfiet (no concerns about falling or lack of visibility). My son started with bike rides on my bakfiet when he was 4 months old. Silly fear-mongering by the AAP.

  10. There’s a middle ground here — Vision Zero. Let’s build a world were no one dies in a car crash. We need doctors and engineers to cooperate. A person on-foot or on-bike will survive most motor vehicle impacts at less than 20 mph. So let’s limit motor vehicle speeds on streets with people present to 20 mph, or separate the people from motor vehicles.

    I encourage folks to read this short essay:

    I can imagine the American Academy of Pediatric embracing Vision Zero. The *leading* cause of death for children is motor vehicle crashes. It doesn’t have to be that way.

  11. I agree with you; five is not a large numerator. As other folks on this page have pointed out, it is not clear
    what denominator to use, or how large that number is. The most popular rear child seat is the 2,962nd best selling product in the Sports and Outdoors category on a large Internet retailer (the most popular handlebar seat is ranked #6,541). It seems like a mistake to use 20 million as the denominator when there are likely millions of U.S. children who will never ride in a bike seat.

  12. I pedaled my two sons across America on a trailabike and chariot trailer when they were 5 and 7. Then pedaled with three sons 9,7 and 1 by tandem, trailabike and Chariot trailer across Canada. Number of injuries and accidents zero – take that back, we had a bit of a scrapped forehead due to an epic lightsaber battle in Yellowstone – five year old shouldn’t have been standing on the log when his brother, “Luke I am your father”ed him. Point is, life has risk. Riding you kids around by bike, which I have done almost every day of their lives, is safe. You have to use commonsense and good equipment and don’t live in fear or read silly fear pamphlets by Docs from Orange County.

  13. Kids love public transit. I was on a bus a few weeks ago with 25 kindergarten students. I was going to get them to sing “The Wheels on the Bus” but their teachers would not let them. Too bad.

  14. Since “If you’re hit by a car” is the worry, why isn’t there a public statement warning drivers of motor vehicles that they are dangerous? Totally ignorant to accuse bicycle drivers as being the problem.

  15. and she goes from intelligent analysis of the abysmal lack of development of safety technology for young children on bicycles to a knee-jerk call for he elimination of automobiles.

  16. I’m sure you mean besides the rules saying that drivers must give a bicycle in or encroaching on a traffic lane the entire lane to themselves and remain far enough away from the bicycle that if the rider falls over for any reason, there will not be a collision.

  17. I can certainly agree with the idea of keeping pedestrians off streets where the traffic speed exceeds 20 MPH.

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