Car Seat Safety: What Every Pediatric Practice Should Know

(that was never taught in residency or RN classes)

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Housekeeping Details

Webinar February 21, 2012

Dr. Alisa BaerPediatrician & NHTSA Certified Child Passenger Safety

Instructor

What every pediatrician needs to know about car seats

thecarseatlady.com

Why is this IMPORTANT?

Car Seat Safety is the ONLY topic

the AAP recommends

discussing at EVERY

well child visit

Car Crashes are the #1 Cause of

DEATH and INJURY for Kids 3-14 Yrs

95% of all car seats are NOT used

properly

BUCKLING UP

BABY

http://www.theartzoo.com/pictures/accessories/rainbow-shoelaces.jpg

LOOSE

SNUG

Most Shoulder Strap Covers TOO LONG

• Talk to the child: “Your straps are snug like a hug”

• Talk to the parent: Validate: child will notice straps being

snugger - suggest that parent replies “your straps are giving you a hug because they love you” the 1st time - & afterwards ignore or distract

Encourage: Allow child to buckle themselves as much as possible

Praise: frequent praise for participation & behavior

“Routine Book” to ease transitions

Buckling Up Behavioral Strategies

STAY WARM &

STAY SAFE

No Coats or Snowsuits

Snowsuit ON OFF

Falsely Snug Dangerously Loose

Swaddle OVER Straps

Magic Coat Trick #1

NOT SAFE in Bulky Coats

Dress for 50 Weather UNDERStraps

o

Put Coat on OVER

Straps

Magic Coat Trick #2

Unzip Jacket & Get Straps SnugZip Jacket OVER Straps

•Car seat = Parachute: 2 things you would never do when wearing a parachute harness:

1. loosen your harness because it was “too tight”

2. Wear anything fluffy under your harness

•Demonstrate in the office how to buckle baby in properly

Buckling Up Talking Points

Head Position &

Airway Obstruction

WITH

WITHOUT

Most Head Inserts are REMOVABLE & OPTIONAL

Many Parents Buy “Aftermarket” Inserts

Chin-To-Chest

Tonkin SL. NZ Med J 1998

Normal AirwayAirway Occluded with Head Flexion

WITH head insert - chin on chest

WITHOUT head insert -

Airway unobstructed

Head Inserts often WORSEN Head Position

WITH head insert - chin on chest

WITHOUT head insert -

airway unobstructed

Head Inserts often WORSEN Head Position

Rolled Burp Cloths

Snug Straps Proper Recline

45o

2 Steps to a SAFE Head Position

•10% hospitalized at least 1 night

•85% of the injuries due to falls

•65% fell out of the car seat

•15% fell from a height:•Shopping cart•Table•Counter Top

8,300 Infants per Year Injured in

Car Seats NOT During a Crash

Shital N, et al. Pediatrics 2010

Rear-facing Only Convertible

Why Rear-facing?

...it’s 5 TIMES SAFERthan forward-facing

(even for 2 year olds)!Henary B, et al. Injury Prevention

2007

12-month-old Forward Facing

Why Rear-facing? Younger child’s head is larger in proportion to body

Why Rear-facing? Younger child’s bones are still

changing from cartilage to bone

Cartilage Bone

Image (C) VolvoBurdi AR et al. J Biomech 1969

0-12 month

1-3years

3-6years

adult

12-month-old Rear Facing

Rear-Facing until age 2 (at least!)

Too Heavy

Too Tall

35-45 pounds usually

Head 1 inch below top of seat usually

AAP Committee on Injury, Violence & Poison Prevention. Pediatrics. 2011Watson E, et al. BMJ. 2009

O’Neill J, et al. Clinical Pediatrics 2011

Reasons Drivers Chose Forward Facing Direction for a Child Younger than 2

Years

O’Neill J, et al. Clinical Pediatrics 2011

Parents believe child is too big for rear-facing long before child

actually is

Of these ONLY ONE child actually had outgrown their rear-facing

seat

O’Neill J, et al. Clinical Pediatrics 2011

Reasons Drivers Chose Forward Facing Direction for a Child Younger

than 2 Years

But what about their legs?

3y 2m - 37 lbs

1y 2m - 18 lbs

2y 2m - 35 lbs

3y 6m - 38 lbs

3y 4m - 34 lbs

2y 1m - 27 lbs

2y 1m - 27 & 32 lbs

Forward-facing kids also sit in

uncomfortable-looking positions

2y 5m - 38 lbs

3y 10m - 38 lbs

2y 10m - 40 lbs

and so do adults...

note: putting feet on airbag (as shown) is dangerous

Besides, there are MORE leg injuries to forward-facing

kids than rear-facing kids

Arbogast KB, et al. Annu Proc Assoc Adv Automot Med. 2002

she won’t wake up

with a stiff neck

...but you sure would

Rear-facingTalking Points

Parents are listening!

O’Neill J, et al. Clinical Pediatrics 2011

• Minimum of 2 years is just that - a minimum

• Validate:

• 12-15 months is typically the most difficult time for kids in car seats (or any device with straps) - as kids realize that these completely limit their independence & mobility

• Legs will look scrunched & uncomfortable - but child will be comfortable

Rear-facing Talking Points

To keep older child happy:

• Remove head rest so child can see better out the rear window

• Sit the car seat more upright (when manufacturer allows) to give child better view

Rear-facing Talking Points

Forward-Facing 5-point harness as long as possible

Too Heavy

Too Tall

Usually 40-65 pounds (few to 85 pounds)

Shoulders at top shoulder strap slotOR

Top of ears at top of seat

7y 6m - 55 & 76lbs

Forward-Facing Head Movement

Head is SAFER With a TETHER

LATCHTethers are part of...

LowerAnchors andTethers forCHildren

Lower Anchors

Rigid Attachment Flexible Attachment

• Safety must be a NON-NEGOTIABLE

• Majority of parents enter into a negotiating relationship with child at age 4 regarding where and how child will be restrained in vehicle - this should NOT be the case

• Many children outgrow their convertible seat before they are ready for a booster

• Advise parents to look for seats with high shoulder strap slots & weight limits

• Minimum to transition from 5-point-harness to booster:

• 4 years AND 40 pounds AND able to sit still in a booster

Forward-facing Talking Points

Nomenclature

5-Point-Harness(Car Seat)

Booster

High Back Booster

Backless Booster

Booster = Positioning Device

iihs.org

Dangers of Poor Lap Belt Fit

Spinal Cord InjuryPhoto: CIREN

Dangers of Poor Lap Belt Fit

Photo: CIREN

Intestinal Rupture

Splenic Laceration

Bladder Rupture

Why Doesn’t Lap Belt Fit Properly Without a Booster?

16-months

5 years

adolescent

1

23

4

56

1

2 3

4

5 6

1 2

NUMBER OF BONES IN THE HIP & PELVIS

Images (C) BoneClones

Hip Bones Underdeveloped

Kids Slouch to Allow Knees to Bend

Dangerous!Lap Belt on Abdomen

How Does a Booster Improve Lap Belt Fit?

Poor Good Lap Belt Fit With Booster

Lap Belt: On AbdomenKnees: Don’t Bend

Naturally Child will Slouch

No Booster

With Booster

Poor Good Lap Belt Fit With Booster

Lap Belt: On AbdomenKnees: Don’t Bend Naturally Child will Slouch

No Booster

Lap Belt: Flat on ThighsKnees: Bend Naturally Child WON’T Slouch

For belted children, abdominal injuries were the 2nd most common injuries (head injury was most

common)

For booster children, there was a notable absence of abdominal injuries

Photos: CIRENArbogast KB, et al. Pediatrics 2009

Boosters Can Eliminate Abdominal Injuries

iihs.org

Dangerous

Uncomfortable

Shoulder Belt Rubbing Neck is NOT Dangerous

... but putting the shoulder belt UNDER your arm or BEHIND your back IS VERY DANGEROUS

Dangerous head movement with shoulder belt under arm

or behind back

BoosterShoulder belt

under armShoulder beltbehind back

Boosters Help Prevent Head

Injuries

Slouching Head Injuries

Excessive Head Movement with Slouching

Booster: YesSlouching: No

Booster: NoSlouching: Yes

How Much Difference Does a

Booster Make?

Arbogast KB, et al. Pediatrics 2009

Boosters Prevent 45% More Injuries than a Seat Belt

38% Reduction

Additional 45% Reduction

4-8 year old children

Arbogast KB, et al. Pediatrics 2009

Are High Back Boosters SAFER than Backless Boosters?

large study found no difference in

injury rates between the 2 booster types

Everyone NeedsWhiplash Protection

Good =

to Top of Ears

Carpools

64% of parents of 4-8 year-olds

carpool...

Macy ML, et al. Pediatrics 2012

• Of the parents who use a booster for their child in their own car...•Only half always have their child use a booster when riding with friends who do not have boosters

•1 in 5 do not always ask other drivers to use a booster seat for their child

Common Obstacles to Booster Usage

... But I Can’t Fit 3 Boosters in My Vehicle

Narrowest Booster: Bubble Bum (12 inches)

Bubble Bums Make 3-Across Possible

(tiny) Volkswagen Golf

... But I Can’t Get My Hands in to

Buckle the Child in the Booster

1 2 3 4

Booster with belt fastened

Climbing under

belt

Tightening seat

belt

Readyto

go!

Climbing into a Buckled Belt

...But How is Abby Supposed to Carry a

Booster Around With Her All Day?

Lightest Booster:Bubble Bum - weighs 1

pound

• INVOLVE THE CHILD

• Teach child 5-step-test & how a booster works

• If buying a new seat, let child select (from 2 or 3 choices)

• Empower parent to resist the peer pressure (from child and other parents) to stop using a booster sooner than is safe

• Backless is just as safe as High Back (in most cases)

• State Laws are NOT enough to keep kids safe - most kids need a booster until age 10-12

• Squirmy kids - lock the belt

Booster Talking Points

Back Seat Until AT LEAST Age 13

EVERYONE Buckles Up

Mayrose J, et al. J Trauma 2006

Cummings P, et al. JAMA 2004Ichikawa M, et al. Lancet 2002

5 Pounds 90 Pounds18Gx =

20mph crash

Resources

Resources Slide Show• Printable Tip

Sheets for Parents• Many in

Spanish and in other languages

• Posters for your office

• Technical Information

• Local Resources

www.seatcheck.org

www.TheCarSeatLady.com

Thank you for participating today!

An evaluation form is available on our website: http://www.miemss.org/EMSCwww/CPSHome.htm; or,

it can be emailed to participants. Upon receiving the evaluation, we can send you a certificate for

participation and information about our other materials and services available on child passenger safety.