It Takes a Village: Prevention of Vehicular Heatstroke in the Childcare Setting Kristie C. Reeves-Cavaliero, Pharm.D. President and Co-Founder, Ray Ray’s Pledge™ (a project of KidsAndCars.org)

©Ray Ray’s Pledge™ 2014 Today’s Program is Dedicated to: The memory of Sophia Rayne “Ray Ray” Cavaliero – The future car safety of Giana Rayne and Kiara Rayne

©Ray Ray’s Pledge™ 2014 Forgotten in the Backseat: More Common than You Think

©Ray Ray’s Pledge™ The number of child hot car deaths reported in the media since 1990 Data on file. KidsandCars.org, 2013.

©Ray Ray’s Pledge™ 2014 Forgotten Daycare Drop-off The #1 source of child hot car deaths

©Ray Ray’s Pledge™ 2014 Objectives Provide brief overview of child vehicular heatstroke (“child hot car deaths”) Understand the most common scenarios in which child hot car deaths occur Review common ways to prevent child hot car deaths Discuss future heatstroke training requirements and childcare accountability

©Ray Ray’s Pledge™ 2014 Heat-Related Illness A spectrum of symptoms due to excessive heat exposure Key initial physical sign to distinguish mild illness vs. heatstroke: Core temperature: ≥104˚F: heatstroke Becker J. Am Fam Physician 2011; 83(11):

©Ray Ray’s Pledge™ 2014 Thermoregulation The body’s methods to maintain a healthy temperature Conduction Direct transfer of heat from a warmer surface to a cooler surface Evaporation Perspiration Radiation Absorption or reflection of heat without direct contact Eg: reflection of heat with light-colored clothing Convection Exchange of heat with surrounding air Becker J. Am Fam Physician 2011; 83(11):

©Ray Ray’s Pledge™ 2014 Heatstroke Also known as “hyperthermia” Body temperature exceeds 104˚F + Body’s thermoregulatory mechanism is overwhelmed and can no longer cool itself + Symptoms: Central nervous system effects: disorientation, sluggishness, hallucinations, seizure, loss of consciousness Other: hot/dry skin that is flushed but not sweaty, rapid heart rate, other heart rhythm disturbances Body temperature >107˚F: organs shut down, cellular damage Fatal if not rapidly reversed Becker J. Am Fam Physician 2011; 83(11): Accessed 12/1/11.

©Ray Ray’s Pledge™ 2014 Heatstroke in Children Children are more prone to overheating than adults: Immature thermoregulatory system: less efficient than adults A child’s body overheats 3-5 times faster than an adult body Adults more likely to modify behavior based on environment (eg: remove excess clothing, get out of a hot car) Tsuzuki-Hayakawa K and Tochihara Y. Eur J Appl Physiol 1995;72:12–17. Accessed 12/1/11.

©Ray Ray’s Pledge™ 2014 Child Vehicular Heatstroke: An Unintended Consequence of Moving Children to the Backseat Accessed 3/15/14.

©Ray Ray’s Pledge™ 2014 Child Injury from Front Passenger Airbag Deployment 49 Deaths; 19 Serious Injuries (1993- Nov. 1997) Marshall KW. AJNR Am J Neuroradiol 1998; 19:1599–1607. * N=12 N=8 N=37 N=11 *40 children unrestrained or improperly restrained *8 child deaths reviewed: 2 properly restrained; 6 improperly restrained or not restrained

©Ray Ray’s Pledge™ 2014 Front Airbag Death vs. Backseat Heatstroke Death Average deaths per year Was the Solution More Dangerous? Where is the Public Outrage? 10* 38 *Most deaths involved children who were forward-facing and either unrestrained or improperly restrained Marshall KW. AJNR Am J Neuroradiol 1998; 19:1599–1607. Data on file, KidsAndCars.org.

©Ray Ray’s Pledge™ 2014 Child Deaths Due to Vehicular Heatstroke: Why Are We Talking About It? Accessed 12/1/11. NiTS Data. nrd.nhtsa.dot.gov/Pubs/ pdf. Accessed 3/15/14. nrd.nhtsa.dot.gov/Pubs/ pdf Vehicular Heatstroke: 3 rd leading cause of death! #1 cause of non-crash, non-traffic child car fatalities!

©Ray Ray’s Pledge™ 2014 Child Vehicular Heatstroke: Understanding the Cause Data from 494 child hot car deaths (1998 – 2010) Accessed 12/1/11. Graph Courtesy of Jan Null, CCM. More than 1 in 5 heatstroke DEATHS Kids were supposed to go to DAYCARE that morning FORGOTTEN in the backseat instead Whereabouts went unquestioned

©Ray Ray’s Pledge™ 2014 Understanding the Cause (cont.) KidsAndCars.org All-Heatstroke Fatality Data (1990 – 2012; n = 651)

©Ray Ray’s Pledge™ 2014 Children Left in Vehicles: How Hot? How Fast? Rate of temperature rise in first 20 minutes: 6.25˚F/ 5 minutes Overall rate of temperature rise through 60 minute study: 3.1˚/ 5 minutes 80% of temperature rise in first 30 minutes Temperature rise begins within five minutes of shutting off ignition Temperature begins to plateau at 60 minutes McClaren C et al. Pediatrics 2005; 116:e Accessed 12/1/11.

©Ray Ray’s Pledge™ 2014 “How Can ANYONE Forget that a Child is in the Backseat??” “If you’re capable of FORGETTING your CELLPHONE, you are potentially capable of FORGETTING your CHILD” David Diamond, Ph.D., USF Weingarten G. Fatal Distraction. IN: Washington Post Feature-Writing.

©Ray Ray’s Pledge™ 2014 Common Factors Associated with Parents Who Forgot their Children Stress Emotion Lack of sleep Change of routine Weingarten G. Fatal Distraction. IN: Washington Post Feature-Writing. Feature-Writing

©Ray Ray’s Pledge™ 2014 …..in other words…. What parent IS NOT at risk of forgetting a child in the backseat?

©Ray Ray’s Pledge™ 2014 Prevention Efforts: It Takes a Village!

©Ray Ray’s Pledge™ 2014 Three Easy Prevention Steps Accessed 3/15/14.

©Ray Ray’s Pledge™ 2014 LOOK before you LOCK™ Recommended by: NHTSA, KidsAndCars.org, Ray Ray’s Pledge

©Ray Ray’s Pledge™ 2014 Ray Ray’s Pledge™ Accessed 3/15/14.

©Ray Ray’s Pledge™ 2014 Car Seat Alarms? Suddenly Safe ‘N Secure Systems (SSNSS) Weight-activated devices Smartphone-activated devices (NEW!) Safety 1 st convertible car seat built-in alarm (NEW!) TOMY iAlert Car Seat Alarm system built-in to car seat Baby Alert International Car seat harness clip-based devices Weight-activated devices

©Ray Ray’s Pledge™ 2014 Future Directions in Vehicular Heatstroke Safety 2012 US Transportation Bill: “Unattended Passenger Reminder” Provisions Safety research initiative Development of performance requirements to warn driver of presence of backseat passenger after vehicle motor is disengaged

©Ray Ray’s Pledge™ 2014 Future Directions (cont.) HHS 45 CFR Part 98 (Child Care and Development Fund Program) (a) (3) (xi): transportation and child passenger safety training

©Ray Ray’s Pledge™ 2014 Future Directions (cont.) State Childcare Heatstroke Training/ Absence Verification Requirements TX AC Chapter 746: Minimum Standards for Childcare Centers (Jacob’s Law) 2 hr annual transportation safety training Requirement for child presence reminder alarms on daycare vehicles Ray Ray’s Pledge (or equivalent) Absence verification requirements in 5 states

©Ray Ray’s Pledge™ 2014 For Heatstroke Information Please Visit Us: Sophia Rayne “Ray Ray” Cavaliero – Instagram: rayrayspledge Youtube: ray rays pledge