We learn about the AAP recommendations for car seat use, installation tips, and how to manage newborns who need a car seat tolerance test before nursery discharge. We are joined by Chelsea Anderson, MD, MHS, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. Today, we'll be discussing car seat safety. We're recording remotely due to the COVID pandemic. We are joined today by Dr. Chelsea Anderson, Assistant Professor in the UT Southwestern Division of Neonatal-Perinatal Medicine and a colleague in the Newborn Nursery.
Dr. Neeta Goli:
Hi Dr. Anderson, thanks for joining us today.
Dr. Chelsea Anderson:
Hi, I'm excited to be back.
Dr. Neeta Goli:
Before a family goes home from the newborn nursery, they must have an appropriate car seat for their baby to ride in. Can you review for us what the AAP's recommendations are on car seat use?
Dr. Chelsea Anderson:
Sure, absolutely. First of all, the motor vehicle accidents are a leading cause of death in children four years and over, and nearly 1000 children, less than 16 years of age, do die in motor vehicle crashes each year in the US. We know that use of a child safety seat can reduce injuries significantly by 71-82%, and reduce deaths by 28%. The goal of the AAP policy is to optimize passenger safety from birth through adolescence, and this is based on four evidence-based best practices.
Dr. Chelsea Anderson:
First of all, for infants, infants should remain in a rear-facing car safety seat as long as possible, per the weight and length specifications of that seat. This position provides the optimal support for the head and spine, especially given the infant's relatively larger head size. Texas law recommends that infants be rear-facing as long as possible, but it only requires for an infant to remain in a rear-facing car seat until one year of age. So it's important to highlight that AAP really emphasizes the benefits of remaining rear-facing for two years or more, until that child reaches the weight or height limits allowable by the car seat manufacturer.
Dr. Chelsea Anderson:
Second of all, after a child has outgrown the rear-facing weight and height limit, they will move to a forward-facing car seat with a harness, and they should remain in a forward-facing car seat until at least four years of age, but they can remain in a forward-facing seat for about four to seven years of age, depending on the child's height and weight.
Dr. Chelsea Anderson:
The next step will be a belt-positioning booster seat, which can be used following when the child has outgrown the forward-facing requirements, until at least eight years of age. The child can usually stay in the booster seats until 8-12 years, and that's when the lap-and-shoulder belt will begin properly fitting the child, when they are four-foot-nine and above.
Dr. Chelsea Anderson:
The next progression from a belt-positioning booster seat is to a lap-and-shoulder belt. The lap-and-shoulder belt should fit properly. The shoulder belt should cross between the middle of the shoulders and chest when the child sits back against the seat. A child younger than 13-years-old should continue to ride in the rear seat of the vehicle.
Dr. Chelsea Anderson:
It's important to note that with each progression in the series, there's a decrease in protection, so we want to delay these transitions as long as possible. For example, for a two-year-old, a two-year-old is five times less likely to die or be seriously injured, if they're in a rear-facing car seat versus a forward-facing. The AAP urges pediatricians to promote these recommendations at every health supervision visit, and this is very important because we know that the majority of car seats and booster seats are misused. 72% are said to be misused, and this is often because parents feel overwhelmed with the amount of choices and lost with the complex installations and features.
Dr. Neeta Goli:
Speaking of difficulty with all the installation and features, parents will often ask if we will actually check their car seat installation before they go home. Now, as the baby's clinicians, we personally don't do that. However, at Parkland, we are lucky that the people who take the mom out to the car seat are actually car seat installation technicians. What are some basic installation tips that we and parents should be aware of?
Dr. Chelsea Anderson:
Yes. It's very important to note that every car seat manufacturer and car model can have unique features, and I certainly cannot teach you to install a car seat by audio. I can review some basic tips, however.
Dr. Chelsea Anderson:
And yes, Parkland does have child passenger safety technicians. Several of the transporters have undergone the training and certification course to be child passenger safety technicians, and to assist families at the time of discharge. A select fewer of them have undergone training to assist with children with special healthcare needs for those specific types of seats, which I'm referring to car beds.
Dr. Chelsea Anderson:
For your installation of the seat, there are several factors which are important, and the steps of this process includes selection of the appropriate seats. That depends on the age, the weight, the developmental level of the child, and the needs of the family. The direction of the seat, so choosing the appropriate rear-facing or forward-facing direction. The location of the seat within the car, which depends on the needs of the family and also the child, and then installation of the seat and harnessing.
Dr. Chelsea Anderson:
First of all, it's important to look at the seat, make sure that you review the expiration date, and the weight and height limits of the seat to make sure that the seat is appropriate for the baby, and then to install the car seat according to the car seat manufacturing guidelines.
Dr. Chelsea Anderson:
You should ensure that you have the correct reclining angle, if the child is being positioned in a rear-facing seat prior to securing the seat into the car. When you attach to the base of the car seat or the car seat into the car, using the seat belt or the LATCH system, and after attachment and tightening, grip the seat near the belt path and pull the seat side-to-side and in a forward movement. To make sure that your seat is properly attached, the seat should move no more than one inch, either side-to-side or in a forward movement.
Dr. Chelsea Anderson:
After attachment, we'll look at harnessing. First, before placing the baby into the car seat, ensure that the harness path is straight and there's no twisting of the belt. After placing the baby into the harness, pull slack from the hip strap before pulling the shoulder snug and clipping the harness clip at armpit level. The harness should be tight enough that you can not pinch excess webbing when doing a pinch test near the baby. The harness level should sit at or below the shoulder level for an infant who is in a rear-facing seat. For a child who's in a forward-facing car seat, the harness level should be at or above the shoulder.
Dr. Chelsea Anderson:
One of our colleagues in the Injury Prevention Department has created an excellent graphic of a newborn infant harnessed into a rear-facing car seat. This makes it a lot easier to visualize all the tips that I've reviewed in a pictorial form. There'll be a link to this handout on our website.
Dr. Neeta Goli:
And I will try to put that in the episode information for our listeners.
Dr. Chelsea Anderson:
It's important to know that you should not use any additional items that do not come with the car seat. That includes extra padding and covers, as those have not been crash-tested with the seat. The infant should not be left in the car seat after travel. The seat should only be used for travel within the vehicle. Avoid leaving the infant in the car seat following completion of your trip.
Dr. Neeta Goli:
And then you did mention that kids should not be left in the car seat after the car journey is over. For our listeners, sometimes you'll have parents who say their baby would sleep in the car seat, but again, that is not in line with our safe sleep recommendation. The car seat is not a safe sleep surface. While they might be asleep in the car seat during car journeys, when they are at home, they should be in a flat, safe surface.
Dr. Chelsea Anderson:
And then a few tips for booster seats. You may choose a backless versus a high-back booster seat, depending on the height of the back seat and of the headrest. The child's ears should not be above the top of the seat or headrest, and always buckle the booster seat into the car even when the child is not riding on it. This is to prevent the seat from becoming a projectile in the event of a crash.
Dr. Chelsea Anderson:
After installing and harnessing your child, it's important to get the installation and harnessing inspected by a car seat technician. You can find an inspection station at the website, NHTSA.gov. If you don't have an inspection station within your area, you can also find a technician using the website, Safe Kids Worldwide.
Dr. Neeta Goli:
Is Safe Kids Worldwide dot-com or dot-org?
Dr. Chelsea Anderson:
Safekidsworldwide.org
Dr. Neeta Goli:
Okay, thank you. And then are there any special considerations for families going into the winter time as far as winter coats go?
Dr. Chelsea Anderson:
Yes, excellent point. Thank you for bringing that up. All blankets or thick coats need to be removed as you harness the baby into the car seat. This is so that the harness is in direct contact with the baby without any interference from other objects. If it is cold and the baby's needing some additional items, you can put the blanket around the baby after the baby has been appropriately harnessed into the car seat.
Dr. Neeta Goli:
Dr. Anderson, sometimes parents will also ask me which seat in the car is the safest. How do you typically answer this question?
Dr. Chelsea Anderson:
That's a more complex question to answer, but the back middle seat is generally the safest position in the car, as it is most removed from potential impact. However, the use of this seat may not meet the needs of the family who has, for example, multiple children, or require easy access to the car seat, because they need to use the car seat in multiple vehicles or frequently putting the baby in and out of the car seat.
Dr. Chelsea Anderson:
The back side seats in the back seat on either side position can be desirable options. It's important to note in this case, the presence of side airbags and review the car vehicle owner's manual. This will specify whether the car seat can or cannot be installed close by the vehicle side airbags. In general, a car seat should be able to be installed safely in the side seat without risk of injury.
Dr. Chelsea Anderson:
The golden rule is that a rear-facing car seat should never be placed in front of an active front airbag.
Dr. Neeta Goli:
Okay. Essentially meaning that the car seat should never be in the front seat of the car.
Dr. Chelsea Anderson:
The safest position for the car seats will be in the back seat of the car. There are certain rare scenarios where families don't have other options, where you can talk about using the front passenger seat, but I would prefer to use the blanket statement that your car seats should be secured in the back seat.
Dr. Neeta Goli:
And then at Parkland, you yourself have developed an initiative for us to perform a car seat test on certain infants. Could you tell us more about which babies need this test, how the test works and what we're looking for?
Dr. Chelsea Anderson:
Yes. This is an initiative to implement car seat testing prior to discharge for high risk infants. Our high risk population will be infants that are preterm, low birth weight, or have certain medical conditions which require car seat testing. These can include hypotonia, trisomy 21, micrognathia, or infants who have had a heart surgery.
Dr. Chelsea Anderson:
These infants are at risk for having apnea, bradycardia or desaturations while being transported in a semi-reclined position. This is due to their low birth weight and also physiologic immaturity of the infant. This is suspected to be due to a lateral slouching of the head and neck that occurs in the semi-reclined position, causing an airway obstruction and hypoventilation.
Dr. Chelsea Anderson:
Special considerations may be required to safely and properly position such infants in their car seats. It's also important to make sure the car seat is appropriate for the low birth weight or preterm infant, and that the infant weight falls within the car seat recommended weight limit. Though, most rear-facing infant seats will fit a lower weight limit of four to five pounds.
Dr. Neeta Goli:
How do we do the car seat test?
Dr. Chelsea Anderson:
The car seat testing is currently done in the Parkland Newborn Nursery. The infant is taken from the mother's room to the nursery, where he's attached to oxygen, heart, and apnea monitors. The infant is observed by a nurse for 90 minutes while the vital signs are monitored, and we will judge whether an infant has passed or failed based on whether we observe an event during that 90 minute timeframe.
Dr. Neeta Goli:
What kind of events are you referring to?
Dr. Chelsea Anderson:
An event will refer to an occurrence of apnea, bradycardia, or desaturation.
Dr. Neeta Goli:
And then what happens if they do have an event?
Dr. Chelsea Anderson:
The immediate step will be to address the vital sign instability. Stimulation, repositioning the infant to first address the unstable vital signs, oxygen supplementation, if it's required. Following the event, the infant can be repositioned back in the car seat test, and the test restarted for an additional 90 minutes. If the infant has a second observed event, this is referred to as a failed test.
Dr. Neeta Goli:
What do we do if babies truly fail the test?
Dr. Chelsea Anderson:
If the tests fail, we'll give the baby a second chance. The car seat test can be repeated after 12 to 24 hours. The same processes will be followed. The baby will be tested a second time. If the baby does fail the second car seat challenge, then the infant may require a special needs car seat, which we refer to as a car bed. Basically, it's a transportation seat in which the infant can lie flat and be harnessed into the bed, which can then be connected to your car.
Dr. Neeta Goli:
How long would an infant need to use that car bed?
Dr. Chelsea Anderson:
That's a very interesting question. The length of time that an infant would require a car bed is not well-defined. The infant would need to come back after a chosen period of time to be re-challenged in a car seat, to determine if they're able to kind of maintain their vital signs in the semi-reclined position, that interval, that length of time that an infant would require the car bed, again, it's not determined.
Dr. Chelsea Anderson:
At the close of today's session, I just want to remind our families of the importance of keeping the infant in the rear-facing position for the maximal allowable time, and the need to have the car seat installation inspected by a car seat technician.
Dr. Neeta Goli:
To end today's episode, what is your favorite part of your workday?
Dr. Chelsea Anderson:
There's so many parts of the workday that I really enjoy. Working closely with our patient population at Parkland, and also spending time with the residents and medical students, teaching and having quality time is really rewarding for me.
Dr. Neeta Goli:
Dr. Anderson, thanks so much for joining us today.
Dr. Chelsea Anderson:
Thank you for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests, and do not necessarily reflect the views of the university.