The Infant Car Seat Challenge Pam Homiak, MPH RN CPST-I MIEMSS & Michelle Spencer, RN CPST-I Frederick Memorial Hospital

The Infant Car Seat Challenge “Hot topic” right now in CPS and for hospitals The only available method of testing to see if a conventional car seat is appropriate for a high-risk newborn being discharged home from the hospital This test has been found to be reliable Intent is to prevent cardiorespiratory compromise in newborns as they are being transported home

The Infant Car Seat Challenge: Problems Lack of research Lack of standardization in implementation Lack of resources

The Infant Car Seat Challenge: What We Know Certain newborns are at risk for apnea when riding in a car seat Periods of no breathing can be potentially dangerous Goal: prevent any risks to the newborn’s health & try to ensure their safety while riding in the vehicle Who should be tested? Infants less than 37 weeks gestational age Infants with history of apnea, bradycardia, desaturations Infants with any medical conditions that put them at risk Lung disease requiring oxygen Neurologic diseases Additional airway problems A car seat must be appropriate for the maturity & medical condition of the infant

The Infant Car Seat Challenge: Sources of Information Where are we getting information on the car seat challenge? American Academy of Pediatricians (AAP) Clinical Report (2009) Not a set of rules for physicians, based on systematic review, standard of care, or a legal document Does not specify parameters for fail Riley Children’s Hospital (Dr. Marilyn Bull) Children’s Hospital Boston (Michele DeGrazia, NNP) KIM Conference (Kidz in Motion), annual child passenger safety conference with pre-conference focused on NICU topics

Highlights from the AAP Clinical Report (2009) Car seat monitoring is recommended to determine physiologic maturity and stable cardiorespiratory function for infants < 37 weeks gestational age (and with other risk factors for apnea, bradycardia, desaturation) Use the infant’s own car seat, according to manufacturer instructions (esp. recline angle!) Recommended duration: 90-120 minutes, or length of travel (whichever is longer)

Highlights from the AAP Clinical Report (2009) Use of car safety seats should be limited to travel to prevent complications (i.e. exacerbation of GERD) Conventional car seat with a semi-upright seating position should be used whenever possible Portable medical equipment Should be secured to prevent injury Monitors should have self-contained power source available that will last for twice the duration of travel

Highlights from the AAP Clinical Report (2009) If an infant fails the monitoring period in a conventional car seat, use of a car bed (and another monitoring period) should be considered Before transitioning from a car bed, another monitoring in a car seat should be performed Limit use of other devices that may cause similar respiratory compromise (swings, carriers, backpacks) One parent should ride in the back seat with the car seat or car bed to observe the child Children should never be left unattended in their car seats (in or out of the vehicle)

Car Bed Options Angel Guard (birth – 9 pounds, up to 21.5 inches) Dream Ride (birth – 20 pounds, 19-26 inches)

Educational DVD for Hospitals One copy sent to each hospital in the state for educating staff on the car seat challenge Educational sessions being offered to interested NICUs and newborn nurseries around the state Request a DVD or training: phomiak@miemss.org

Car Seat Testing at Frederick Memorial

History 2003-Initial policy written for Car Seat Testing in the SCN. 2006-Policy updated 2007-Policy updated to include testing in the NBN with an Order set, Car Seat Competency Tool for nursing staff, Information Sheet and Informed Consent for parents.

Car Seat Testing in the NICU All nurses in the NICU have been trained to perform the car seat test. At present there are 3 certified car seat technicians, 1 is an instructor. All infant’s regardless of gestational age are tested prior to DC. Tested at least 1 hour after feeding.

Infant sits for at least 1 hour or the length of the car ride home, whichever is longer. Tested at least one to seven days prior to going home. If infant fails first test, infant is retested a few days later. If infant fails seat test twice, tested in a car bed provided by the hospital, in a side-lying or supine position.

Parents are counseled to avoid other upright positioning devices if infant is sent home in a car bed. An appointment is made with the Wellness Center for 2 weeks after DC to have the infant retested in their car seat by a CPS Instructor/nurse.

Car Seat Testing in NBN All newborns less than 37 weeks gestation and/or less than 5 pounds have a car seat test before DC from the Birthplace or Pediatric Department. Newborn Nursery standing orders for car seat testing are initiated upon the birth of any newborn less than 37 weeks gestation and/or less than 5 pounds.

Parents are given an information sheet and informed consent and have the right to waive the car seat test. Parents provide car seat and infant is placed on cardiac/respiratory monitor and pulse oximeter in the NBN, at least 12 hours after birth. Test is done the same in NBN as in NICU. Core group of Mother-Baby nurses have been trained to do car seat testing.

Parent Education If the car seat provided by the parents is to big for the infant, the hospital has a rental program with seats that start at 4 pounds for use until the infant has grown into their personal seat. Parent education packets on Post-Partum and the NICU provide parents with car seat information. Parents are also encouraged to have help with installing their car seats by certified technicians in the county.

Training All nurses in the NICU are trained to do car seat testing and are signed off with the Competency Tool Core group of nurses on the Birthplace are trained to do car seat testing and signed off with the Competency Tool Will be a mandatory competency to complete at this years Competency Marathon.

Retesting Infant’s that are discharged in a car bed are scheduled to be retested in 2 weeks after DC. Infant’s return to the FMH Wellness Center and are retested in their personal infant seat by a Certified Car Seat Instructor using a pulse oximeter that reads the infant’s oxygen levels and heart rate. Documentation at that time is done on the Safe Kids car seat inspection form; due to the fact that we check the seat installation at that time as well.

Comments Questions?