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An Update on Newborns in Car Safety Seats and the Infant Car Seat

Challenge Test

Today’s PresentersNatalie L. Davis, MD, MMSC, Assistant

Professor of Pediatrics, University of Maryland Hospital for Children;

Claire Myer, MS, CPST/I, Assistant Coordinator, Maryland Kids in Safety Seats

Susanne Ogaitis-Jones, MSPH, CPST, Coordinator, MIEMSS CPS Healthcare Project

Child Passenger SafetyWhat we know, what we use, and what we do

has changed dramatically!

We’ve Come A Long Way – for Baby!

Changes to Rear-Facing Only and RF Convertible Car Seats

More Rear-Facing Only seats with a weight minimum of 4 lbs vs 5 lbs

Some Rear-Facing Convertible seats have a 4 lb minimum weight; 1 RF Convertible has a 3 lb min.

Lower shoulder slot heights: 5.5” up to 8.5”Multiple crotch buckle positions for proper

harness fitManufacturer supplied LBW infant kits,

“pillows”, foam inserts, wedges, and smaller harness retainer clips

Car Bed Options for Infants Who Must Lie Flat

Angel Ride

Birth – 9 lbs

<21.5”

Hope

4.5 – 35 lbs

13 – 29”

Dream Ride SE

5 – 20 lbs

19 – 26”

Infant Car Seat Challenges:Who, What, When, Where, Why and

How?

Natalie Davis, MD, MMScAssistant Professor of Pediatrics

University of Maryland School of MedicineDivision of Neonatology

Objectives• Why do this test? History of the ICSC• Current recommendations on who should be

tested• What failure guidelines should be used?• What to do when a baby fails?• Where is future research focusing? • How should we counsel families when it

comes to ICSCs

Why? Who?

Why do this test? (History of the ICSC)Who should be tested?

Infant Car Seat Challenge (ICSC)• 1970s – AAP recommends infants travel in a car safety seat• 1980s – Evidence that preterm infants at increased risk of

desaturations while in the semi-upright car seat position– Lung immaturity? Breathing immaturity? Low tone?– Too small for the standard seat?

• 1990s – AAP recommends “a period of observation for apnea, bradycardia and desaturations” in the car seat prior to discharge for preterm infants Infant Car Seat Challenge

• 2000s – Evidence that longer time in car seat increases risk of desaturations

• 2009 – Current AAP recommendations:– All infants born <37 weeks – 90-120 minutes, or length of car ride home, whichever is longer– No guidelines for “failure” criteria

Bull MJ, et al. Pediatrics. 2009; Willett. Pediatrics. 1986 and 1989; Salhab. J Pediatr. 2007

Local Statistics

• Premature: born <37 weeks gestation – “Due date” is usually 40 weeks

• USA: 11.5% of babies are born prematurely– 500,000 born prematurely in the US annually

• Maryland: 12.2%• Baltimore City: 13.7%

– Maryland Dept of Health and HumanHygiene, 2012 Vital Statistics

http://en.wikipedia.org/wiki/File:Maryland_in_United_States.svg

Who?

• All babies born <37 weeks gestational age (GA)– Overall failure rate of 4.3%

• 2.4% in infants born early preterm <34 weeks GA• 5.6% in late preterm born 34+0/7 – 36+6/7 weeks GA

• Who else?– Full term babies born <2.5kg– Respiratory issues (home oxygen, airway malformations)– Hypotonia/neurologic issues (Trisomy 21, Prader Willi)– Cyanotic Heart Disease

• 6% failure rate (all full term)

Davis NL, et al. Pediatrics 2013; Simsic JM, et al. Pediatr Cardiol 2008

ICSC: What’s Missing? • No guidelines for what constitutes an ICSC

“failure”• When to perform the test?

– When prior to discharge– In relation to feeds

• Consensus on other groups to test– Low birth weight <2.5kg? Hypotonia?

• What to do if an infant fails?• What does a “failed” infant car seat challenge

mean for the health and safety of that baby?

What?

What failure guidelines should be used?

Results

• Following AAP Guidelines– 11% did not perform ICSCs– 17% did not test all infants born <37 weeks GA– 45% tested for <90 minutes

• Additional Criteria– 45% included “Low Birth Weight” as a testing

criterion, testing all babies born <2.5kg– No consensus on failure criteria for bradycardia or

desaturations

Davis NL, et al. Academic Pediatrics. 2013

Davis NL, et al. Academic Pediatrics. 2013

Davis NL, et al. Academic Pediatrics. 2013

Davis NL, et al. Academic Pediatrics. 2013

Conclusions• Many NICUs not following AAP guidelines

• Lack of consensus on clinically significant desaturation criteria

• If the ICSC does in fact detect significant desaturations, current testing protocols may be missing at-risk infants

• Differential care based on hospital of birth, not on clinical differences

Suggested Failure Criteria

• Apnea >20 seconds• Heart Rate <80 beats per minute for >10 seconds• Saturation <90% for >10 seconds • Respiratory distress not improved with proper

positioning

• Canadian Paediatric Society: – Two episodes <88% for >10 seconds

When?

What to do when a baby fails?

Why do they fail?

• Likely multifactorial– Lung immaturity/inflammation

• Low reserve, small lung capacity– Low tone and strength

• Floppy, easily malpositioned, unable to correct neck flexion• Straps compress the chest

– Small size• Poor fit in car seat - neck flexed/occlude airway• Straps hit incorrectly

– Neurologic immaturity and increased risk of apnea• Poor response to low oxygen saturations

What does ICSC failure mean?

• Failed ICSC– No studies on long term outcomes in infants that fail ICSC– Marker of immaturity? Need for closer monitoring?

• Increased incidence SIDS in upright position? Related?

• Passed ICSC– 89% positive predictive value of passing 2 subsequent

tests– 11% passed, then failed a test

• Lower weight• Educate families that a passed test does not mean 100% safety –

still need to:– Position correctly – Monitor closely– Minimize time in the car seat position! Davis NL, Gregory ML, Rhein L. J Perinatol. 2014

Failed ICSC: What are the options?

• Retest in car seat after a period of observation– Immediately– 6 hours– 12 hours– 24 hours

• Test in car bed and d/c in car bed

• Admit for further work uphttp://injury.research.chop.edu/sites/default/files/car_bed.jpg

Safety: Car Seat vs. Car Bed

Car Seat

15% had an eventOne needed test stopped

Time to first event: 55 minutes

Car Bed

19% had an eventOne needed test stopped

Time to first event: 54 minutes

Salhab WA, et al. J Peds 2007

150 VLBW babies born <37 weeks gestationTested in car bed and car seat for 120 minutesRandomly assigned to one, then re-tested in the other mode

28% had an event in BOTHSame number had events after 60 minutes and 90 minutes

Same number needed nursing intervention

Failed ICSC…what next?• No evidence that apnea, bradycardia, and desaturation

episodes are less likely in a car bed than a car seat

• Protection provided by a rear-facing car safety seat is better documented than the protection provided by car beds

• If possible, safest to send them home in a car seat– Wait 12-24 hours and retest in car seat

• Evaluate positioning during the test – location of straps, position of body

• Evaluate car seat for proper sizing– If fails x2, further evaluation

• Consider medical evaluation (any treatable cause? Persistent apnea?)• Discuss with family – retest in car seat• Consider testing in car bed and discharge in car bed

– If fails test in car bed• Further medical evaluation for cause of respiratory/neurologic

distress

IF you must send them home in a car bed…

• Perform a similar period of observation (Infant Car Bed Challenge, ICBC) prior to discharge

• Before transitioning from a car bed to car seat, perform ICSC in the infant’s own semi-reclined car safety seat– At term equivalent (40 weeks) or 2-4 weeks after

discharge– Repeat via pediatrician’s office or at pediatric

pulmonologists office• Test in outpatient clinic• Test as inpatient with polysomnography

Where?

Where is future research focusing?

Future Research

• Incidence and risk factors for failure of the ICSC in full term, low birth weight (<2.5kg) babies

• Recorded oximetry prior to the ICSC to predict failure

• Inserts to improve oxygenation in the car seat• ICSC in all infants?

How?

How should we counsel families?

Best Practice for ICSC

• Discuss the test with the family and the reasons for performing it BEFORE the test.– Performed on premature babies and babies with other

issues that put them at risk of breathing problems – Goal is to make sure their breathing is safe in that position

before they go home– How long is their car ride home?

• Bring in car seat well before anticipated discharge– NICU: 2-3 days before discharge– Full term nursery: bring in as soon as they can– Assess for safety of the seat, appropriate sizing

Best Practice for ICSC

• Test can be done any time of night or day, but make sure parents are aware– Perform >24 hours of life– Ideally perform day prior to discharge

• Perform a “realistic” ICSC – recreate what will be happening at home– Perform within 30 minutes of a feed– Ok to use pacifier if the family will be using this at

home– Use family’s actual car seat

Suggested Failure Criteria

• Apnea >20 seconds• Heart Rate <80 beats per minute for >10 seconds• Saturation <90% for >10 seconds • Respiratory distress not improved with proper

positioning

• Canadian Paediatric Society: – Two episodes <88% for >10 seconds

Failed ICSC• Assess for fit of infant in car seat, appropriateness of

positioning• Update family• Perform repeat ICSC > 12-24 hours from failed test

– Time to recover– Additional day of respiratory maturity and improved tone

• Fail a 2nd ICSC:– Consider test in a car bed

• PASS: discharge in car bed– Follow-up at term corrected or 2-4 weeks of age

• FAIL: recommend medical evaluation – Rule out respiratory, neurologic, cardiac etiology

Counseling Families

• Minimize time in the car seat or semi-upright position– Left sleeping in car seat– Bouncy chairs– Slings – Swings

• Close observation while in the car seat– Try to take breaks during long periods of travel to

allow infant to lay flat

THANK YOU!

-Natalie Davisndavis@peds.umaryland.edu

Anticipatory Guidance for Expectant/New Parents

CPS Technicians:

• Review minimum weight for their RF seat

• Discuss alternative seat options if needed

• Ask questions:• Singleton vs Multiples?• When is due date?• Estimates of baby’s size?• Any concerns?

Health Care Practitioners

Advise patients with high-risk or multiple pregnancies to:

• Purchase RF car seat(s) early

• Look for RF car seat(s) with minimum weight of 4 lbs

• Discuss importance of small harness dimensions

• Refer to CPS Techs/Resources

Free Resources from MIEMSS’ CPS & OP Healthcare ProjectCPS & OP Training for healthcare providers Educational materials & sample policies for

healthcare agenciesScholarships to take the CPST certification courseOn-line continuing education courses and videosConsultation on your agency’s CPS policies and

proceduresYouth/‘pre-driver’ curriculum and train-the-trainer

sessions

One of our free posters…

(11” x 30”)

Our 2009 training DVD for healthcare providers

MD KISS ServicesPresentations/Trainings

Car Seat Check-Up Events

Skype Virtual Inspections/Assistance

Car Seat Assistance Programs

Information & Referrals

Kids In Safety SeatsContact Info:

Helpline: 800-370-SEAT (7328)

Email: dhmh.kiss@maryland.gov

Web: www.mdkiss.org

Skype: mdkiss2

Thank you for participating today!

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