Presentation on theme: "An Update on Newborns in Car Safety Seats and the Infant Car Seat Challenge Test Housekeeping Details Please put your phones on MUTE in order to minimize."— Presentation transcript:
1 An Update on Newborns in Car Safety Seats and the Infant Car Seat Challenge Test Housekeeping DetailsPlease put your phones on MUTE in order to minimize background noise, as the presentation is being recorded so that we can archive the slides & audio on our website.Please save questions/comments until the end of the presentation.Complete and mail back the evaluation form and the participant information form if you want a certificate or CPST--CEUs.
2 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 SeatsSusanne Ogaitis-Jones, MSPH, CPST, Coordinator, MIEMSS CPS Healthcare Project
3 Child Passenger Safety What we know, what we use, and what we do has changed dramatically!
4 We’ve Come A Long Way – for Baby! Instead of adapting the car seat for the child (or hoping that it will work), many rear-facing car seats are designed for babies who weigh 4 pounds or even less.
5 Changes to Rear-Facing Only and RF Convertible Car Seats More Rear-Facing Only seats with a weight minimum of 4 lbs vs 5 lbsSome 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 clipsIt is possible to achieve the correct harness fit with LBW and smaller infants thanks to CR manufacturer responsiveness to real-world issues! CPS Technicians, health care providers, parents, and safety advocates explained to CR manufacturers what was needed, and the manufacturers listened.
6 Car Bed Options for Infants Who Must Lie Flat Dream Ride SE5 – 20 lbs19 – 26”Angel RideBirth – 9 lbs<21.5”Hope4.5 – 35 lbs13 – 29”
7 Infant Car Seat Challenges: Who, What, When, Where, Why and How? Background, hot topicsNatalie Davis, MD, MMScAssistant Professor of PediatricsUniversity of Maryland School of MedicineDivision of Neonatology
8 Objectives Why do this test? History of the ICSC Current recommendations on who should be testedWhat 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
9 Why do this test? (History of the ICSC) Who should be tested? Why? Who?Why do this test? (History of the ICSC)Who should be tested?
10 Infant Car Seat Challenge (ICSC) 1970s – AAP recommends infants travel in a car safety seat1980s – Evidence that preterm infants at increased risk of desaturations while in the semi-upright car seat positionLung 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 Challenge2000s – Evidence that longer time in car seat increases risk of desaturations2009 – Current AAP recommendations:All infants born <37 weeksminutes, or length of car ride home, whichever is longerNo guidelines for “failure” criteria70% reduction in infant death. NHTSA1980 – desats in upright position: BPD, hypotonia floppy head and neck, weak vs. safety strap, aop, doesn’t fit in seat (too big)10 minutes to 60 minutesSalhab et al showed that 30% of desaturations occur after 90 minutesBull MJ, et al. Pediatrics. 2009; Willett. Pediatrics and 1989; Salhab. J Pediatr. 2007
11 Local Statistics Premature: born <37 weeks gestation “Due date” is usually 40 weeksUSA: 11.5% of babies are born prematurely500,000 born prematurely in the US annuallyMaryland: 12.2%Baltimore City: 13.7%Maryland Dept of Health and HumanHygiene, 2012 Vital Statistics
12 Who? All babies born <37 weeks gestational age (GA) Who else? Overall failure rate of 4.3%2.4% in infants born early preterm <34 weeks GA5.6% in late preterm born 34+0/7 – 36+6/7 weeks GAWho else?Full term babies born <2.5kgRespiratory issues (home oxygen, airway malformations)Hypotonia/neurologic issues (Trisomy 21, Prader Willi)Cyanotic Heart Disease6% failure rate (all full term)Davis NL, et al. Pediatrics 2013; Simsic JM, et al. Pediatr Cardiol 2008
13 ICSC: What’s Missing?No guidelines for what constitutes an ICSC “failure”When to perform the test?When prior to dischargeIn relation to feedsConsensus on other groups to testLow 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?
15 Results Following AAP Guidelines Additional Criteria 11% did not perform ICSCs17% did not test all infants born <37 weeks GA45% tested for <90 minutesAdditional Criteria45% included “Low Birth Weight” as a testing criterion, testing all babies born <2.5kgNo consensus on failure criteria for bradycardia or desaturationsDavis NL, et al. Academic Pediatrics. 2013
19 Conclusions Many NICUs not following AAP guidelines Lack of consensus on clinically significant desaturation criteriaIf the ICSC does in fact detect significant desaturations, current testing protocols may be missing at-risk infantsDifferential care based on hospital of birth, not on clinical differences
20 Suggested Failure Criteria Apnea >20 secondsHeart Rate <80 beats per minute for >10 secondsSaturation <90% for >10 secondsRespiratory distress not improved with proper positioningCanadian Paediatric Society:Two episodes <88% for >10 secondsCanada <88% for >10seconds twice
22 Why do they fail? Likely multifactorial Lung immaturity/inflammation Low reserve, small lung capacityLow tone and strengthFloppy, easily malpositioned, unable to correct neck flexionStraps compress the chestSmall sizePoor fit in car seat - neck flexed/occlude airwayStraps hit incorrectlyNeurologic immaturity and increased risk of apneaPoor response to low oxygen saturations
23 What does ICSC failure mean? Failed ICSCNo studies on long term outcomes in infants that fail ICSCMarker of immaturity? Need for closer monitoring?Increased incidence SIDS in upright position? Related?Passed ICSC89% positive predictive value of passing 2 subsequent tests11% passed, then failed a testLower weightEducate families that a passed test does not mean 100% safety – still need to:Position correctlyMonitor closelyMinimize time in the car seat position!Davis NL, Gregory ML, Rhein L. J Perinatol. 2014
24 Failed ICSC: What are the options? Retest in car seat after a period of observationImmediately6 hours12 hours24 hoursTest in car bed and d/c incar bedAdmit for further work up
25 Safety: Car Seat vs. Car Bed 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 modeCar SeatCar Bed15% had an event One needed test stopped Time to first event: 55 minutes19% had an eventOne needed test stoppedTime to first event: 54 minutesSalhab et al 2007 – 150 infants in car seat and car bed – random which first. 1-24hrs in between. All within 72 hrs of d/c. <37 weeks and VLBW <1500g bw, at least 30min after feed, lower cutoff 88%28% had incident in both15% in car seat19% in car bedNo fewer events in car bed – same # needed RN intervention and removal from test.Time to first even 55 and 54 minutesSame # occur after 60 and 90 minutes.1) As reported by other investigators,2, 3, 4 and 5 apnea, bradycardia, and desaturation episodes may still occur at discharge when VLBW infants are placed in a transportation device, particularly among infants who were born most prematurely or who are recovering from BPD; (2) we found no evidence that these episodes are less likely in a car bed than a car seat; (3) a brief observation period in a transportation device is not sufficient to identify infants at risk, but the longer these infants remain in such devices, the more likely oxygen saturation is to fall.28% had an event in BOTHSame number had events after 60 minutes and 90 minutesSame number needed nursing interventionSalhab WA, et al. J Peds 2007
26 Failed ICSC…what next?No evidence that apnea, bradycardia, and desaturation episodes are less likely in a car bed than a car seatProtection provided by a rear-facing car safety seat is better documented than the protection provided by car bedsIf possible, safest to send them home in a car seatWait hours and retest in car seatEvaluate positioning during the test – location of straps, position of bodyEvaluate car seat for proper sizingIf fails x2, further evaluationConsider medical evaluation (any treatable cause? Persistent apnea?)Discuss with family – retest in car seatConsider testing in car bed and discharge in car bedIf fails test in car bedFurther medical evaluation for cause of respiratory/neurologic distress
27 Discharge in approved car safety seat Fail ICSCPassDischarge in approved car safety seatFailWait > hours and repeat ICSC2nd FailTest in a Car BedDischarge in Car BedReturn for retesting in car seat at term or 2-4 weeks of ageRecommend further evaluation and admission for medical work up
28 IF you must send them home in a car bed… Perform a similar period of observation (Infant Car Bed Challenge, ICBC) prior to dischargeBefore transitioning from a car bed to car seat, perform ICSC in the infant’s own semi-reclined car safety seatAt term equivalent (40 weeks) or 2-4 weeks after dischargeRepeat via pediatrician’s office or at pediatric pulmonologists officeTest in outpatient clinicTest as inpatient with polysomnography
30 Future ResearchIncidence and risk factors for failure of the ICSC in full term, low birth weight (<2.5kg) babiesRecorded oximetry prior to the ICSC to predict failureInserts to improve oxygenation in the car seatICSC in all infants?
32 Best Practice for ICSCDiscuss 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 problemsGoal is to make sure their breathing is safe in that position before they go homeHow long is their car ride home?Bring in car seat well before anticipated dischargeNICU: 2-3 days before dischargeFull term nursery: bring in as soon as they canAssess for safety of the seat, appropriate sizing
33 Best Practice for ICSCTest can be done any time of night or day, but make sure parents are awarePerform >24 hours of lifeIdeally perform day prior to dischargePerform a “realistic” ICSC – recreate what will be happening at homePerform within 30 minutes of a feedOk to use pacifier if the family will be using this at homeUse family’s actual car seat
34 Suggested Failure Criteria Apnea >20 secondsHeart Rate <80 beats per minute for >10 secondsSaturation <90% for >10 secondsRespiratory distress not improved with proper positioningCanadian Paediatric Society:Two episodes <88% for >10 secondsCanada <88% for >10seconds twice
35 Failed ICSCAssess for fit of infant in car seat, appropriateness of positioningUpdate familyPerform repeat ICSC > hours from failed testTime to recoverAdditional day of respiratory maturity and improved toneFail a 2nd ICSC:Consider test in a car bedPASS: discharge in car bedFollow-up at term corrected or 2-4 weeks of ageFAIL: recommend medical evaluationRule out respiratory, neurologic, cardiac etiology
36 Counseling FamiliesMinimize time in the car seat or semi-upright positionLeft sleeping in car seatBouncy chairsSlingsSwingsClose observation while in the car seatTry to take breaks during long periods of travel to allow infant to lay flat
37 THANK YOU! -Natalie Davis firstname.lastname@example.org
38 Anticipatory Guidance for Expectant/New Parents CPS Technicians:Review minimum weight for their RF seatDiscuss alternative seat options if neededAsk questions:Singleton vs Multiples?When is due date?Estimates of baby’s size?Any concerns?Health Care PractitionersAdvise patients with high-risk or multiple pregnancies to:Purchase RF car seat(s) earlyLook for RF car seat(s) with minimum weight of 4 lbsDiscuss importance of small harness dimensionsRefer to CPS Techs/ResourcesTake advantage of “teachable moments” with expectant parents during prenatal visits or car seat check-up events.
39 Free Resources from MIEMSS’ CPS & OP Healthcare Project CPS & OP Training for healthcare providersEducational 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 sessionsView these webinars:Be-Tween Riding & Driving: Educating Youth on In-Car SafetySusanne Ogaitis-Jones, MSPH, CPST, at MIEMSS; Kelly Llewellyn, RN, EMS Administrative Specialist, Meritus Medical Center, and Oluranti Omoyeni, RN,Johns Hopkins Bayview Medical Center.Happy Children in Safe Seats: Not As Easy As It SoundsCaroline Langrall, BSN, CCLS, CPST, Nurse at Johns Hopkins Hospital and Child Life Specialist at Mt. Washington Pediatric Hospital.Safe Transport of Children in AmbulancesCyndy Wright Johnson, MSN, RN and Danielle Joy, NREMT-P, MS, Emergency Medical Services for Children, MIEMSS Buckling Up Challenges & Strategies for Hard-to-Reach GroupsJewel Johnson, Child Passenger Safety Instructor; Danitza Simpson, Director, Adelphi & Langley Park Family Support Center, and Susanne Ogaitis-Jones, MSPH.Car Seat Safety: What Every Pediatric Practice Should KnowAlisa Baer, MD, CPST/I, NICU Hospitalist at Children’s Hospital of New York
40 Our 2009 training DVD for healthcare providers One of our free posters…(11” x 30”)
41 MD KISS Services Presentations/Trainings Car Seat Check-Up Events Skype Virtual Inspections/AssistanceCar Seat Assistance ProgramsInformation & Referrals
42 Kids In Safety Seats Contact Info:Helpline: SEAT (7328)Web:Skype: mdkiss2
43 Thank you for participating today! Final Instructions:The evaluation form is available on our website: or it can be ed to you.Return your completed evaluation to get a certificate of participation.If you are a CPST, your certificate is proof that you earned 1 CEU toward your CPST recertification.If you want to order materials, note what you would like on the contact information form.This webinar (PPT and audio) will be available on our website in a couple of weeks in case you wish to re-visit it, or refer a colleague to it.