The Healthcare Provider’s Role in Child Passenger Safety

www.pakidstravelsafe.org 1-800 CAR BELT

The Healthcare Provider’s Role in

Child Passenger SafetyPA Chapter

American Academy of PediatricsTraffic Injury Prevention Project


Goals of ProgramExplain the Pennsylvania laws concerning child passenger safety.

Describe “best practice” concerning child safety seats.

List key educational messages regarding proper use of child restraints.


According to the law (§ 4581. Restraint systems)—subsection Occupant StandardsA child passenger restraint system and a child booster seat shall be used as designated by the manufacturer of the system in motor vehicles equipped with seat safety belts and shall meet the Federal Motor Vehicle Safety Standard. Children between the ages of 8 and 18: Must be properly restrained in a vehicle seat belt system.

All drivers are responsible for securing children in the appropriate child restraint system.

All children from birth up to age 4 must be secured in an approved child safety seat anywhere in the vehicle. Violators of this primary law are subject to a fine of $75.00 plus Court Costs, EMS, MCARE, and Administrative Fees. Total cost $161.00

All children age 4 up to age 8 must be secured in a seat belt system and appropriate child booster seat anywhere in the vehicle. Violators of this primary law are subject to a fine of $75.00 plus Court Costs EMS, MCARE and Administrative Fees. Total cost $161.00

All children age 8 up to age 18 must be secured in a seat belt system anywhere in the vehicle. Violators of this primary law are subject to a $10 fine plus EMS, MCARE, and Administrative Fees. Total cost $60.00

Child Passenger Safety Law


Hospitals Role in CPS PA Vehicle Code Section 4583(a) Availability of restraint devices – the hospital, in conjunction

with the attending physician, shall provide the parents of any newborn child with any information regarding the availability of loaner or rental programs for child restraint devices that may be available in the community where the child is born.

(b) Instruction and education programs –The department shall provide instructional and educational program materials through all current public information channels and to all relevant State and Federally funded, community based programs for maximum distribution of information about this child passenger protection law.


Why Are We Here? Traffic crashes are still the leading cause of unintentional deaths and severe injuries in the United States. Only diseases like cancer, heart disease, and stroke kill more people than motor vehicle crashes. Every day in the United States, an average of 4 children age 14 and younger were killed and 490 were injured in motor vehicle crashes during 2009.


NHTSA Statistics / CRS Use

NHTSA 2009 Survey Restraint use for children age 1 to 3 years

increased from 92 % in 2008 to 96 % in 2009 Restraint use for all children under age 13

remained unchanged at 89%Note: Restraint use for all children from birth to 7 years old stood at 88 percent in 2009 as compared to 87 percent in 2008 from the 2009 National Occupant Protection Use Survey (NOPUS)

41 percent of 4 to 7 year-old children ride in booster seats Virtually unchanged from the prior year.

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2010 PA Crash Facts CRSAs shown below (2006-2010 crashes involving children under age four), the % of deaths and injuries (within restraint type by row) were lower when restraints were used. From 2006-2010, 82% of the children under age four who were involved in crashes and restrained in a child seat sustained no injury.


2009 PA Child Traffic FatalitiesAge 14 and under by Age Groups <1 - 2 1 - 3 years - 3 4 - 7 years - 12 8 - 14 years -15

Total Child Traffic Fatalities 14 & under = 32


Fatalities & InjuriesFatalities are just the tip of the iceberg:

For every 1 death there are:

45 injuries requiring hospitalization and1100 other injuries requiring medical care.


Three Collisions in a Crash1st: Vehicle collision 2nd: Human collision

3rd: Internal collision3rd1st 2nd


Child Restraint Effectiveness

71% effective in reducing deaths for infants. 54% for 1 to 4 year olds. Reduces the need for hospitalization by 69%.


5 Ways Restraints Prevent Injury

1. Prevents ejection.2. Contacts the strongest parts of

the body.3. Spread forces over a wide area of

the body.4. Helps the body to “ride down”

the crash.5. Protects the head and spinal

cord.


NEW AAP Guidelines for Car Seat Use All infants and toddlers should ride in a rear facing car safety seat until they are 2

years of age or until they reach the highest weight or height allowed by their car seat's manufacturer.

All children 2 years or older, or those who have outgrown the rear facing weight or

height limit for their car safety seat, should use a forward facing car safety seat with a harness for as long as possible, up to the highest weight or height allowed by their car safety seat's manufacturer.

All children whose weight or height is above the forward facing limit for their car

safety seat should use a belt positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 ft 9 inches in height and are between 8 & 12 years old.

When children are old enough and large enough to use the vehicle seat belt alone,

they should use a lap and shoulder belt. All children younger than 13 should be restrained in the rear seat of the vehicle.


AlgorithmAAP Policy Released March,

2011


NHTSA New GuidelinesNHTSA New Guidelines


Selecting the Correct Child Restraint

Correct selection is based on the child’s: Age Weight Height Physical

Development Behavioral Needs


Rear Facing Position

“All infants and toddlers should ride in a Rear Facing Car Safety Seat until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer.”


Rear Facing Only (Infant Seat)

Rear facing ONLY. Birth/4-5 pounds

to 20 – 22 (most models) or 30/35 pounds.

When the head is 1” below top of shell. Chicco Key Fit 4-30lbs

with newborn/preemie insert


Rear Facing Talking Points Never place a rear facing car seat in front of

an active passenger side air bag (front seat). Until age 2, children are at least 75% safer rear-facing than forward-facing.

Article Injury Prevention 2007; 13: 398-402 Car Safety Seats for children: rear facing for best protection

Children in the second year of life (12-24 mos.) are over 5 times less likely to be seriously injured or die in a crash if riding rear facing.

Article Injury Prevention 2007; 13: 398-402

Follow manufacturers instructions for using and installing car seat at the appropriate angle.


Rear Facing & Forward Facing Crash Tests

Rear Facing video Forward Facing video


Development of the neck vertebrae


Rear Facing Only (Infant Seat)

Supports entire head, neck & back, reducing stress to neck and spine in a crash.

May have a 5-point or V-harness.

Some have a detachable base.

Check instructions for angle and angel indicator


Rear Facing Convertible Rear facing until 20 to 30/45 lbs and a

minimum of one year old. Use in a semi-reclined position. Tray not appropriate for premature or

small infant.

Tray Shield Five Point Harness


Convertible Seats RF Longer

Nearly every convertible seat on the market has a 30/35lbs rear facing max. weight limit. These are only three examples of convertible seats that can be used rear-facing to 40 or 45lbs

Graco My Ride 65 Safety Surround 40lbs RF

Safety First Complete Air 40lbs RF

Diono Radian 100, 120 & RXT 40 & 45lbs RF models


Securing Child In Rear Facing Seats

Back & bottom flat into CRS. Rolled cloth at crotch strap, if necessary. Rolled blankets at sides for positioning. Harness at or below the shoulders. Retainer clip at armpit level.

Always follow the manufacturer’s instructions.


AAP Strengthens AAP Strengthens Long Standing Long Standing

AdviceAdvice The AAP has strengthened its advice that

CRs and other sitting devices are not recommended for routine sleep for infants

They have included the warning that infants younger than 4 months are particularly at risk in these seating environments because they “might assume positions that can create risk of suffocation or airway obstruction.”


Pinch Test

Test at child’s shoulder

Try to pinch webbing up and down

Your fingers should slide off

Harness straps are too loose


Rear-Facing Back Angle Back is primary

restraint Balance with comfort

and keeping airway open

Range - 30o to 45o - according to manufacturer’s instructions

Newborns more reclined

More upright as child grows

Car bed option for special needs

3030°°4545°°

Level with Level with the Groundthe Ground


Forward Facing Position “All children 2 years or

older, or those younger than 2 who have outgrown the rear facing weight or height limit of their car safety seat should use a Forward Facing Car Safety Seat with a harness for as long as possible, up to the highest weight or height allowed by their car safety seat’s manufacturer.”


Forward Facing Convertible “Turn Around Time” Can forward face (after

minimum of 1 year and 20 lbs.), longer if seat allows up to 30-35/45 lbs.

Starting at 18-24 months in age.

Most seats have harnesses that go up to 40lbs. Some car seats have harnesses up to 65 lbs.

Seat in upright or semi-upright position.

Adjust recline angle to uprightAlways follow the manufacturer’s instructions.


Forward Facing Convertible Seat

Harness: 5-Point

(recommended) Tray Shield

Harness in the reinforced slots at or above shoulders.

Generally, must use top slots when forward facing.


Forward Facing Only Seats Forward facing for

children over 1 year and 20 to 40-65 lbs. Some HW models may

even go to 80 lbs. (Seat shown)

Some can ONLY be used with the harness.

Some have a removable harness.

Britax Regent FF min 1yr. 22lbs to 80lbs. 53” or less


Forward Facing Combination Seats

Combination child safety seat / boosters:

Forward facing only.

Most have a 40 pound weight limit for the internal harness. Some car seats may accommodate higher weights, 50-65lbs.

Must remove the harness and use with lap and shoulder belt for the BPB when reach max. harness weight or height.

Combination Harness/BPBHarness to 70lbs and a booster to 120lbs.


Harness Rules: Forward

3. Tightness: SNUGShould not be able to pinch any

slack in the harness.

2. Harness Retainer Clip: Armpit or Mid-chest level.

1. Slots: Convertible Seats: Top slot or above the reinforcement bar.

Forward Facing Only Seats: First level at or above the shoulders.


Four Elements to Achieve a Correct Installation

1. Direction – Rear facing vs forward facing.2. Location in the vehicle.

Children are 37% less likely to die when seated in a back seat.

Seat selection is based on the needs of all passengers.

3. Correct belt path – Follow the manufacturer’s instructions.

4. Tight Installation.


LATCHLower Anchors and Tethers For Children


LATCH Lower Anchor Locations in Vehicles


TETHERS


Why Use a Tether Strap?(Credit: Lower Anchors and Tethers for Children – 2005, Safe Ride News Publications)

Tether strap can improve performance of CR when its use is recommended by the manufacturer.

Reduces the forward movement and rotation of the seat

Adds additional stability to CR installation


Belt-Positioning Booster “All children whose

weight or height is above the forward-facing limit for their car safety seat should use a Belt-Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age.”


Booster SeatsProvide a transition from CR with

harness to a vehicle lap and shoulder belt.

Minimum weight ranges: 30-40 lbs.Maximum weight ranges: 60-120 lbs. Max. height limits vary

High back booster

Backless booster


Why a Booster Seat?

1. Protects children too large for a CR with harness but too small for a simple seat belt.

2. Increases crash protection from injuries

Incorrect belt fit because there is no

booster seat

Correct belt fit with belt-

positioning booster


Basic Booster Seat Reminders WARNING:

Belt-positioning booster seats can only be used with lap and shoulder combination safety belts.

Belt-positioning booster seats must NEVER be used with just a lap belt.

Play VideoCourtesy Children’s Hospital of Philadelphia


Securing Children In Booster Seats

Requires Lap & Shoulder belt.

BPB fits flat on vehicle seat between safety belt anchors.

Lap belt positioned low across top of thighs and shoulder belt across chest.

Knees bend comfortably.

Child has appropriate head restraint.

Shoulder belt positioners


Seat Belt Syndrome

Spinal cord or soft tissue damage due to:

-Improper placement of lap belt over the abdomen.

-Lap belt that rides up onto abdomen.


Lap and Shoulder BeltsLap and Shoulder Belts

“When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection.”


Seat Belts

1. Sit all the way back.

2. Knees bend comfortably at the edge of the seat.

3. Lap belt fits low on hips, touching thighs.

4. Shoulder belt crosses center collar bone and center chest.

5. Must be able to stay for the entire trip.


Proper Belt Fit Prevents…

Courtesy Children’s Hospital of Philadelphia


CHILD PASSENGER SAFETY FOR SPECIAL NEEDS


AAP Policy Statement StatusSafe Transportation of Newborns at Hospital Discharge

By AAP Committee on Injury, Violence, and Poison Prevention

Published in 1999 Reaffirmed in 2003, 2006

Safe Transportation of Premature and Low Birth Weight Infants – now a Clinical Report

By AAP Committee on Injury, Violence, and Poison Prevention and Committee on Fetus and Newborn

Published in 1996 Released May 2009

Selecting and Using the Most Appropriate Car Safety Seats for Growing Children: Guidelines for Counseling Parents By AAP Committee on Injury, Violence, and Poison Prevention Published in 2002Under revision – completion in 2010?


CRS For Small InfantsInfant Seats that start at birth:

Combi Shuttle: birth to 33lbs & 33” w/ base new model Combi Navette: birth to 22lbs seated height 18”or less (inst.

sales) Orbit G2 Infant Car Seat: up to 22 lbs / 29”

Infant seats with a 3 to 4-pound minimum include: Aprica A30 4-30lbs Britax Chaperone: 4-30 lbs / 32” Chicco Key Fit & Key Fit 30: 4-22 lbs / 30” 4-30 lbs 30” Cybex Anton: 4-32 lbs / 30” Evenflo Embrace 35: 4-35 lbs Evenflo Secure Ride 35 4-35lbs (in process changing to 4lbs.) Graco new Snug Ride 35 4-35 lbs mia Moda Certo: 4 to 22 lbs / 29” Safety First Comfy Carry Elite 4-22lbs Safety First On Board 35 Air 4-35 lbs. / 32” Summer Prodigy Infant Seat 4-32 /32”

Safety First On Board 35 Air


CRS For Small InfantsCRS For Small InfantsConvertible seats that start at 3 or

4lbs:Combi Coccoro: RF 3-33 lbs (FF 20-40lbs) Dorel Maxi Cosi Pria 70 RF 4-40 lbs (FF22-70lbs) Graco Classic Ride 50 4 - 40 lbs (FF 20-50lbs)Graco My Ride 65 Safety Surround RF 4–40 (FF

20-65)Coming Soon: Feb. 2012 Graco My Size 65 4-40lbs


AAP Clinical Report Replaced the 1996 policy statement

Safe Transportation of Premature and Low Birth Weight Infants

Reviewed by AAP Board of Directors What’s new?

More evidenceMore specific clinical guidance Length of time 90 -120 min. or length of travel

whichever is longer

Retest in car bed if failed tolerance test and car bed is being considered

Follow up should be addressedNew section on research implications


extend the “observation period” of the child in his/her child restraint prior to discharge of low birth weight or premature infants to 90-120 minutes, or the length of travel home, whichever is the longest. The report also recommends that a trained staff member perform this observation.

provide interventions such as a car bed, supplemental oxygen, continued hospitalization, and further medical assessment if the child fails the observation period.

provide additional observation periods after the child is discharged and prior to moving the infant from a car bed to a rear-facing infant restraint.

limit the time preemies and low birth weight infants spend in child restraints to essential travel.

Summary AAP Clinical Report


Special ConditionsHigh Risk Infants:

Any infant<37 weeks gestation, low birth weight or with any medical condition that places the child at risk for apnea, bradycardia or oxygen desaturation.

These infants must undergo a period of observation to assure safety in the semi-reclined CRS prior to discharge.

This is necessary regardless of where the baby is housed in the hospital (NICU, NB nursery, Pediatric Floor).


Special ConditionsOther “High Risk” medical conditions: Children with developmental delays. Children with neuromuscular conditions. Children with chronic lung disease or

oxygen requirement. Children with severe GERD

or other GI conditions.


Perform an observation period in the CRS to be used.

Position infant in seat properly for optimum restraint use

Maintain the proper recline angle approved for car seat use (no more than 45o) during the monitoring.

May stabilize infant with lateral rolls on the side to maintain position and a crotch roll to prevent submarining.

Monitoring should be done within 1- 7 days prior to discharge.

Monitoring should be done for a minimum of 90 to 120 minutes or the expected travel time, whichever is longer.

Any infant who develops apnea, bradycardia or oxygen desaturation, as defined by testing guidelines, during the observation has failed the testing.

Review Tolerance Testing Procedures


Recommendations when failed testing: Consider further medical evaluation and intervention.

Consider continued hospitalization until stable.

Consider supplemental oxygen.

Consider retesting in a car bed appropriate for the weight and size of the infant.

Parents should be counseled to avoid other upright positioning devices including swings, infant seats and infant carriers.

If the infant is discharged in a car bed, the physician should consider scheduling a retest at a later time to assess the infant’s readiness to graduate to standard child restraint and ride in the rear-facing semi-upright position.


Car Seat/Car Bed Challenge Codes

The AAP has been successful in getting Current Procedural Terminology (CPT) codes assigned to car seat car bed challenge test. Effective 1-1-12

94780: Car seat/bed testing for airway integrity, neonate, with continual nursing* observation and continuous pulse oximetry, hear rate and respiratory rate, with interpretation and report; 60 minutes

94781: Each additional full 30 minutes of the procedure described in code 94780

AAP Clinical Report Recommends 90-120 minutes or the length of the travel time home


Angel Guard Angel Ride Car Bed

< 9 pounds < 20” Supine Right-side positioning or prone only if medically necessary Premature or low birth weight infants


Pediatrician’s Role in Child Passenger Safety

First interaction: prenatal visit

Second interaction: hospital discharge

Third interaction: first office check-

up


When You Only Have 5Minutes in the Office


What you can you do in the office?

Non-regulated products

Children that have outgrown or too small

for their seat

Focus on best practice and what you can see that is not correct.

Harness loose, twisted , retainer clip too low - not at armpit level


Healthcare Provider’s Role in

Child Passenger SafetyParents Need To Know: Always read Manufacturer’s instructions Infant seats for newborns better fit Don’t use non-regulated products Second hand seats not recommended Life span of car seat / seat expirations Back seat is safest Enough safe seating for multiple children Some retail seats can be used for Special

Needs and some Medical Car Seats can be Prescribed.


Child Passenger Safety Update

Review of what’s new: LATCH various designs Lap and shoulder belts in all

positions Harness Adjustment designs Ease of Use Ratings Higher weight seats -call PA

TIPP for updated list /AAP Shopping Guide online RF: 5lbs to 40lbs

FF: 20lbs to 65lbsBPB: 40lbs to 100lbs


New Features Anti rebound bar Side Impact Protection Lock Offs Car Seats that give you feedback?


NHTSA Ease-of-Use 5-Star Ratings: NHTSA uses a five-star rating system to help consumers evaluate the four basic category ratings:

= Excellent features on this child

restraint for this category.

= Above average features on this child restraint for this category.

= Average features on this child restraint for this category.

= Below average features on this child restraint for this category.

= Poor features on this child

restraint for this category.

N/A = Does not contain any features

that require a rating.www.nhtsa.dot.gov


NHTSA website has info. sheets in English and Spanish that you can use:

Trunk EntrapmentTrunk Entrapment Power WindowsPower Windows Vehicle RollawayVehicle Rollaway Seat Belt EntanglementSeat Belt Entanglement Hyperthermia & HeatstrokeHyperthermia & Heatstroke BackoverBackover



Child Passenger SafetyHelpful hints: Keeping children

buckled Testing limits Suggestions



Child Passenger Safety Be a resource

Provide current materials

Certified CPS technician on staff

Staff Trainings

Child safety seat clinics


Resources PA TIPP PA Traffic Injury Prevention Project 1-800-CAR BELT

www.pakidstravelsafe.org www.paaap.org

www.nhtsa.dot.gov

THANK YOU


PA Chapter American Academy of Pediatrics Traffic Injury Prevention Project

Rose Tree Corporate Center II1400 N. Providence Road

Suite 3007Media, PA 19063-2043

1-800-CAR-BELTwww.pakidstravelsafe.org

The Healthcare Provider’s Role in Child Passenger Safety

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