1. PEDIATRIC CONTINUITY CLINIC CURRICULUM CREATED BY: SAFIA ILYAS, PGY-2 CAR SEATS

2. OBJECTIVES Review AAP car seat guidelines and incorporate into appropriate guidance for families Learn how to properly place a car seat in a car Describe the types of car seats available

3. CASE #1 You are doing a meet and greet with a family expecting their first child in a few weeks. At the end of the visit you provide anticipatory guidance about car seat use. What are the current car seat guidelines regarding rear facing car seats? When can a child be transitioned to forward facing car seats? At what age is a booster seat appropriate?

4. DISCUSSION QUESTION 1-1? Infants and toddlers should ride in a rear-facing car seat (infant-only rear facing car seat or rear-facing convertible car seat) until they are at least two years old or until they have reached the weight and height limits of their car seat. If a child continues to fit in their car seat in the rear-facing position beyond two years of age, then it is advised that they continue to remain rear-facing until they grow out of the seat. Although this means that some larger infants and toddlers might have to graduate to a rear-facing convertible car seat All car seats are different as for weight limits, and is important to familiarize yourself with your child’s car seat specifications.

5. DISCUSSION QUESTION 1-2? Once they are two years old (or, regardless of age, have outgrown their rear-facing car seat) toddlers should sit in a forward-facing car seat with harness straps as long as possible and until they reach the weight and height limits of their car seat. Keep in mind that many convertible car seats and combination car seats have forward-facing weight limits of 65 to 80 pounds when used with harness straps.

6. DISCUSSION QUESTION 1-3? Kids can next move to a belt-positioning booster seat when they reach the weight and height harness strap limits of their forward-facing car seat. The move to regular seat belts should not occur until kids are 4 feet 9 inches tall (57 inches) and are between 8 and 12 years old. All kids under 13 years of age should sit in the back seat, using an age-appropriate restraint.

7. ADDITIONAL INFORMATION

8. CASE #2 A new parents comes to your office for their daughter’s newborn exam. You ask to make sure she is being transported in a rear-facing car seat and that is appropriately sized for her. What is the proper way to install a car seat? How can you confirm that a car seat is properly installed? What about placing a car seat in a pickup truck?

9. DISCUSSION QUESTION 2-1? Car safety seats may be installed with either the vehicle’s seat belt or the LATCH (Lower Anchors and Tethers for Children) system. LATCH system Lower anchors can be used instead of the seat belt to install the seat The top tether improves the safety provided by the seat and is important to use for all forward- facing seats, even those installed using the vehicle seat belt. All lower anchors are rated for a maximum weight of 65 pounds(total weight of car safety seat plus the child). New car seats have the maximum weight of the child allowed for use of the lower anchors printed on the label. Vehicles with the LATCH system have lower anchors located in the back seat, where the seat cushions meet. Tether anchors are located behind the seat, either on the panel behind the seat (in sedans) or on the back of the seat, ceiling, or floor (in most minivans, SUVs, and hatchbacks). Nearly all passenger vehicles and all car safety seats made on or after September 1, 2002, are equipped to use LATCH.

10. DISCUSSION QUESTION 2-1? Seat belts: Check the vehicle owner’s manual to see if you need a locking clip to keep the belt locked into position. Locking clips are not needed in most newer vehicles, but you may need to fully extend the seat belt first and then allow it to retract in order to keep the seat belt tight around the car safety seat.

11. DISCUSSION QUESTIONS 2-2 AND 2-3? Tight is Right - make sure your car seat is installed tightly using a seat belt, or LATCH if it is available. I If, when holding the bottom of the car seat, you can move the seat more than 1 inch, then it may not be installed tightly enough. Pickup Trucks : children should never be allowed to ride in the cargo area of a pickup truck Smaller rear seats of some compact extended-car pickup trucks may not be as safe as other cars and trucks with larger back seats.

12. CASE #3 You are seeing a 24-month old toddler for his WCC in your office. At the end of the visit, his mother asks when he should transition to another car seat. What types of car seats are available? What ages and weights are they appropriate for?

13. REAR FACING SEATS 3 types: rear-facing only seats, convertible seats, and 3-in-1 seats Rear-Facing Only : For newborns and small babies; small, portable seat; for infants up to 22-40 pounds Babies usually outgrow their infant car seats by eight or nine months. Should be used only for travel Convertible seat : As a child grows, can be changed from a rear-facing seat to a forward-facing seat with a harness and tether. For infants up to 40-50 pounds Include 5-point harness that attaches at shoulders, hips, and between legs Should be used only for travel All in One Seat: Can be used rear-facing, forward-facing, or as belt-positioning booster Higher rear-facing weight and height limit

14. REAR FACING SEATS Place the harnesses in your rear-facing seat in slots that are at or below your baby's shoulders. Ensure that the harness is snug. Harness clip should be positioned at the center of the chest and at the level of the child’s armpits. Never place a rear-facing car seat in the front seat of a vehicle If you are using a convertible or 3-in-1 seat in the rear-facing position, make sure the seat belt or lower anchor and tether is routed through the correct belt path. Check the instructions that came with the car seat to be sure. Check the instruction manual to find out the correct angle for your seat and how to adjust the seat angle if needed. All rear facing seats have built-in angle indicators or adjusters. Check the car seat instructions and the vehicle owner’s manual about whether the car seat may contact the back of the vehicle seat.

15. FORWARD FACING SEATS Any child who has outgrown the rear- facing weight or height limit for their convertible car seat should use a forward-facing car seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. It is best for children to ride in a seat with a harness until at least to 4 years of age. If your child out-grows out of his or her seat before reaching 4 years of age, consider using a seat with a harness approved for higher weights and heights.

16. FORWARD FACING SEATS There are 5 types of car safety restraints that can be used forward-facing. Convertible seats: Can "convert" from rear-facing to forward-facing. These include 3-in-1 seats. Forward-facing-only seats: Can be used forward-facing with a harness for children up to 40-80 pounds Combination seat with harness —Seats can be used forward-facing with a harness for children who weigh up to 40-90 pounds (depending on the model) or without the harness as a booster (up to 80-120 pounds, depending on the model). Built-in seats: Some vehicles come with built-in forward-facing seats. Do not use built-in seats until your child is at least 2 years of age. Travel vests: Can be worn by children between 20 and 168 pounds. Useful for when a vehicle has lap-only seat belts in the rear or for children whose weight has exceeded that allowed by car seats.

17. FORWARD FACING SEATS To switch a convertible or 3-in-1 seat from rear-facing to forward-facing: Move the shoulder straps to the slots that are at or above your child's shoulders. You may have to adjust the recline angle of the seat so that it sits more upright in your vehicle. If using a seat belt, make sure the seat belt runs through the forward-facing belt path If using the lower anchors, follow car seat and vehicle owner's manual instructions. Always use the top tether when you can. A tether is a strap that is attached to the top part of a car seat and holds the seat tightly by connecting to an anchor point in your vehicle (often on the seat back or rear shelf).

18. BOOSTER SEATS Booster seats: Are for older children who have outgrown their forward-facing car seats. For children whose weight or height is above the forward-facing limit for their car seat should use a belt-positioning booster seat until the vehicle seat belt fits properly (typically when height at least 4 feet 9 inches and are between 8 and 12 years of age). As a general guideline, a child has outgrown his forward-facing seat when any one of the following is true: Child reaches the top weight or height allowed for his seat with a harness. These limits are listed on the seat and also included in the instruction booklet Child’s shoulders are above the top harness slots. Child’s ears have reached the top of the seat.

19. BOOSTER SEATS There are 2 types of booster seats: high-back booster seats and backless booster seats. Do not come with harness straps but are used with the lap and shoulder seat belts in your vehicle, the same way an adult rides. Raise the child up so that the lap and shoulder seat belts fit properly over strong bones. Simply rest on the vehicle seat and are held in place once the seat belt is fastened over the child. Some models of booster seats can be secured to the vehicle seat and kept in place using the lower anchors or top tether. Booster seats should be used until child can correctly fit in the adult lap and shoulder seat belts, 4 feet 9 inches in height and 8 to 12 years old. Installation Tips for Booster Seats Often have a plastic clip or guide to correctly position the vehicle lap and shoulder belts. Booster seats must be used with a lap and shoulder belt. When using a booster seat, make sure: The lap belt lies low and snug across your child's upper thighs. The shoulder belt crosses the middle of your child's chest and shoulder, and is off of the neck. If your booster seat has lower anchors or top tether attachments, check the booster seat manual for installation instructions.

20. REFERENCES AND FUTURE READING http://www.healthychildren.org/English/safety- prevention/on-the-go/Pages/Car-Safety-Seats- Information-for-Families.aspx http://www.healthychildren.org/English/safety- prevention/on-the-go/Pages/Car-Safety-Seats- Information-for-Families.aspx http://www.safercar.gov/parents/Car-Seat- Types.htm http://www.safercar.gov/parents/Car-Seat- Types.htm http://pediatrics.about.com/od/carseats/a/car- seat.htm http://pediatrics.about.com/od/carseats/a/car- seat.htm http://www.wesh.com/news/florida-booster-seat- laws-for-children-to-change-in-january/25741288 http://www.wesh.com/news/florida-booster-seat- laws-for-children-to-change-in-january/25741288