1. 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 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 Presenters
Natalie 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 Seats
Susanne 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 lbs
Some 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 fit
Manufacturer supplied LBW infant kits, “pillows”, foam inserts, wedges, and smaller harness retainer clips
It 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 SE
5 – 20 lbs
19 – 26”
Angel Ride
Birth – 9 lbs
<21.5”
Hope
4.5 – 35 lbs
13 – 29”

7. Infant Car Seat Challenges: Who, What, When, Where, Why and How?
Background, hot topics
Natalie Davis, MD, MMSc
Assistant Professor of Pediatrics
University of Maryland School of Medicine
Division of Neonatology

8. Objectives Why do this test? History of the ICSC
Current recommendations on who should be tested
What 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 seat
1980s – Evidence that preterm infants at increased risk of desaturations while in the semi-upright car seat position
Lung 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 Challenge
2000s – Evidence that longer time in car seat increases risk of desaturations
2009 – Current AAP recommendations:
All infants born <37 weeks
minutes, or length of car ride home, whichever is longer
No guidelines for “failure” criteria
70% reduction in infant death. NHTSA
1980 – 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 minutes
Salhab et al showed that 30% of desaturations occur after 90 minutes
Bull 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 weeks
USA: 11.5% of babies are born prematurely
500,000 born prematurely in the US annually
Maryland: 12.2%
Baltimore City: 13.7%
Maryland Dept of Health and Human
Hygiene, 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 GA
5.6% in late preterm born 34+0/7 – 36+6/7 weeks GA
Who else?
Full term babies born <2.5kg
Respiratory issues (home oxygen, airway malformations)
Hypotonia/neurologic issues (Trisomy 21, Prader Willi)
Cyanotic Heart Disease
6% 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 discharge
In relation to feeds
Consensus on other groups to test
Low 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?

14. What failure guidelines should be used?

15. Results Following AAP Guidelines Additional Criteria
11% did not perform ICSCs
17% did not test all infants born <37 weeks GA
45% tested for <90 minutes
Additional Criteria
45% included “Low Birth Weight” as a testing criterion, testing all babies born <2.5kg
No consensus on failure criteria for bradycardia or desaturations
Davis NL, et al. Academic Pediatrics. 2013

16. Davis NL, et al. Academic Pediatrics. 2013

17. Davis NL, et al. Academic Pediatrics. 2013

18. Davis NL, et al. Academic Pediatrics. 2013

19. Conclusions Many NICUs not following AAP guidelines
Lack of consensus on clinically significant desaturation criteria
If the ICSC does in fact detect significant desaturations, current testing protocols may be missing at-risk infants
Differential care based on hospital of birth, not on clinical differences

20. Suggested Failure Criteria
Apnea >20 seconds
Heart Rate <80 beats per minute for >10 seconds
Saturation <90% for >10 seconds
Respiratory distress not improved with proper positioning
Canadian Paediatric Society:
Two episodes <88% for >10 seconds
Canada <88% for >10seconds twice

21. What to do when a baby fails?

22. Why do they fail? Likely multifactorial Lung immaturity/inflammation
Low reserve, small lung capacity
Low tone and strength
Floppy, easily malpositioned, unable to correct neck flexion
Straps compress the chest
Small size
Poor fit in car seat - neck flexed/occlude airway
Straps hit incorrectly
Neurologic immaturity and increased risk of apnea
Poor response to low oxygen saturations

23. What does ICSC failure mean?
Failed ICSC
No studies on long term outcomes in infants that fail ICSC
Marker of immaturity? Need for closer monitoring?
Increased incidence SIDS in upright position? Related?
Passed ICSC
89% positive predictive value of passing 2 subsequent tests
11% passed, then failed a test
Lower weight
Educate families that a passed test does not mean 100% safety – still need to:
Position correctly
Monitor closely
Minimize 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 observation
Immediately
6 hours
12 hours
24 hours
Test in car bed and d/c in
car bed
Admit for further work up

25. Safety: Car Seat vs. Car Bed
150 VLBW babies born <37 weeks gestation
Tested in car bed and car seat for 120 minutes
Randomly assigned to one, then re-tested in the other mode
Car Seat
Car Bed
15% had an event One needed test stopped Time to first event: 55 minutes
19% had an event
One needed test stopped
Time to first event: 54 minutes
Salhab 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 both
15% in car seat
19% in car bed
No fewer events in car bed – same # needed RN intervention and removal from test.
Time to first even 55 and 54 minutes
Same # 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 BOTH
Same number had events after 60 minutes and 90 minutes
Same number needed nursing intervention
Salhab 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 seat
Protection provided by a rear-facing car safety seat is better documented than the protection provided by car beds
If possible, safest to send them home in a car seat
Wait hours and retest in car seat
Evaluate positioning during the test – location of straps, position of body
Evaluate car seat for proper sizing
If fails x2, further evaluation
Consider medical evaluation (any treatable cause? Persistent apnea?)
Discuss with family – retest in car seat
Consider testing in car bed and discharge in car bed
If fails test in car bed
Further medical evaluation for cause of respiratory/neurologic distress

27. Discharge in approved car safety seat Fail
ICSC
Pass
Discharge in approved car safety seat
Fail
Wait > hours and repeat ICSC
2nd Fail
Test in a Car Bed
Discharge in Car Bed
Return for retesting in car seat at term or 2-4 weeks of age
Recommend 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 discharge
Before transitioning from a car bed to car seat, perform ICSC in the infant’s own semi-reclined car safety seat
At term equivalent (40 weeks) or 2-4 weeks after discharge
Repeat via pediatrician’s office or at pediatric pulmonologists office
Test in outpatient clinic
Test as inpatient with polysomnography

29. Where is future research focusing?

30. Future Research
Incidence and risk factors for failure of the ICSC in full term, low birth weight (<2.5kg) babies
Recorded oximetry prior to the ICSC to predict failure
Inserts to improve oxygenation in the car seat
ICSC in all infants?

31. How should we counsel families?

32. Best Practice for ICSC
Discuss 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 problems
Goal is to make sure their breathing is safe in that position before they go home
How long is their car ride home?
Bring in car seat well before anticipated discharge
NICU: 2-3 days before discharge
Full term nursery: bring in as soon as they can
Assess for safety of the seat, appropriate sizing

33. Best Practice for ICSC
Test can be done any time of night or day, but make sure parents are aware
Perform >24 hours of life
Ideally perform day prior to discharge
Perform a “realistic” ICSC – recreate what will be happening at home
Perform within 30 minutes of a feed
Ok to use pacifier if the family will be using this at home
Use family’s actual car seat

34. Suggested Failure Criteria
Apnea >20 seconds
Heart Rate <80 beats per minute for >10 seconds
Saturation <90% for >10 seconds
Respiratory distress not improved with proper positioning
Canadian Paediatric Society:
Two episodes <88% for >10 seconds
Canada <88% for >10seconds twice

35. Failed ICSC
Assess for fit of infant in car seat, appropriateness of positioning
Update family
Perform repeat ICSC > hours from failed test
Time to recover
Additional day of respiratory maturity and improved tone
Fail a 2nd ICSC:
Consider test in a car bed
PASS: discharge in car bed
Follow-up at term corrected or 2-4 weeks of age
FAIL: recommend medical evaluation
Rule out respiratory, neurologic, cardiac etiology

36. Counseling Families
Minimize time in the car seat or semi-upright position
Left sleeping in car seat
Bouncy chairs
Slings
Swings
Close observation while in the car seat
Try to take breaks during long periods of travel to allow infant to lay flat

37. THANK YOU! -Natalie Davis ndavis@peds.umaryland.edu

38. Anticipatory Guidance for Expectant/New Parents
CPS Technicians:
Review minimum weight for their RF seat
Discuss alternative seat options if needed
Ask questions:
Singleton vs Multiples?
When is due date?
Estimates of baby’s size?
Any concerns?
Health Care Practitioners
Advise patients with high-risk or multiple pregnancies to:
Purchase RF car seat(s) early
Look for RF car seat(s) with minimum weight of 4 lbs
Discuss importance of small harness dimensions
Refer to CPS Techs/Resources
Take 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 providers
Educational materials & sample policies for healthcare agencies
Scholarships to take the CPST certification course
On-line continuing education courses and videos
Consultation on your agency’s CPS policies and procedures
Youth/‘pre-driver’ curriculum and train-the-trainer sessions
View these webinars:
Be-Tween Riding & Driving: Educating Youth on In-Car Safety
Susanne 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 Sounds
Caroline Langrall, BSN, CCLS, CPST, Nurse at Johns Hopkins Hospital and Child Life Specialist at Mt. Washington Pediatric Hospital.
Safe Transport of Children in Ambulances
Cyndy Wright Johnson, MSN, RN and Danielle Joy, NREMT-P, MS, Emergency Medical Services for Children, MIEMSS  
Buckling Up Challenges & Strategies for Hard-to-Reach Groups
Jewel 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 Know
Alisa 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/Assistance
Car Seat Assistance Programs
Information & 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.