What Is the Scope of Practice for Pediatric Care for Chiropractic Doctors?

Patient Presentation
A new colleague asked a pediatrician if she knew what was the normative scope of practice for chiropractic physicians in the local area. The new pediatrician had a recent newborn being treated by a chiropractic physician for birth trauma and feeding difficulties and was concerned about the care. “I’ve tried to find some information about this kind of practice but I haven’t been able to find any. Where I practiced before the chiropractors usually took care of adults and occasionally a teenager for back pain. Do you know of any information?” he asked. The senior pediatrician said that it wasn’t uncommon for some families in the area who had a less medical intervention health style to go to one or two chiropractic physicians in the area. “I’ve also not had young infants being treated by them, but one in particular has been helpful with a teenager with chronic headaches and backpain. I’ll see if I can find anything that might help you,” she replied.

Discussion
Chiropractic is a health care profession concerned with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health.” Some people look at chiropractic care solely as spinal manipulative therapy (SMT) or manipulation. Chiropractic physicians also offer a variety of other treatments including nutritional advice, dietary or herbal supplements, therapeutic exercise, posture correction and behavioral counseling.

Spinal muscle therapy or spinal manipulation is one of the most common complementary, integrative, and alternative medicine practices used by children in the U.S.. Usually care is sought for musculoskeletal complaints but also infant crying/colic, anxiety/stress, sleep problems, asthma, attention problems and upper respiratory infections including otitis media. Another important reason is overall health promotion.

A literature review regarding different forces used for SMT in children found that there was a range of forces used depending on the study and SMT technique used. This paper cites standards for force relative to adults:

  • Neonates to 2 month olds = < 10% or 11.2 Newtons (N)
  • Children 3-23 month olds = 30% or = 33.6 N
  • Children 2-8 year olds = 50% or 56 N
  • Children 8-18 years = 80% or 89.6 N

One newton is the force needed to accelerate one kilogram of mass at the rate of one meter per second squared in direction of the applied force. As a reference, gravity exerts a force of about 9.8 Newtons on a 1 kilogram mass.

Learning Point
Authors of a recent expert consensus review noted that despite its use, “…the scientific evidence for the effectiveness and efficacy of chiropractic care and spinal manipulation for treatment of children is not plentiful or definitive.” In their 2016 literature review and Delphi Consensus Panel, the authors came up with a summary of the best practices for chiropractic care in children. Their primacy question was “What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by children (<18 years of age)?"

The authors provide a good overview on the approach to the pediatric patient supporting a detailed history and physical examination with attention to “red flags” that need immediate medical referral, appropriate diagnostic imaging, care planning including counseling for a healthy life style which includes immunization counseling with “…balanced, evidence-based information from credible sources and/or refer the parents to such resources.” They note, if SMT is used, then it should be modified for the individual patient based on size, structural development, flexibility of joints and patient preference. Chiropractic physicians, like all health care providers, should consider if they are the sole manager of the health issue, co-manager with other health care providers, or should provide a referral to an appropriate health care provider. The authors do not provide data to support more detailed scope of practice including evidence for treatment for specific conditions. Initially the authors performed a similar consensus process in 2009 to try to address the gaps in the best practices literature. There was little data therefore expert opinion was used. They sought to update the information again in 2016 and came up with a similar result.

This writer attempted to find guidelines from the Agency for Healthcare Research and Quality which cited 1 guideline from the International Chiropractic Association from 2008. This has been superseded on their website by another guideline which does not address the pediatric age group specifically. This writer also attempted to find guidelines from Chiropractors’ Association of Australia (CAA) reported on 5/23/2016, that were also supported by the American Chiropractic Association on 6/1/2016, but the Internet links went to non-usable pages on the CAA website. A search of the CAA website did not find the resource noted. The National Center for Complementary and Integrative Health Chiropractic care page currently does list clinical practice guidelines for adults with musculoskeletal problems. It does not list any resources under the Scientific Literature section. A Cochrane Collaboration review found that there may be a small benefit from SMT in adults for short term, acute and subacute, low back pain but the differences were small.

Questions for Further Discussion
1. What are the training requirements for chiropractic doctors in your location?
2. What are chiropractic doctors general scope of practice in your location?
3. What is the scope of practice of other non physician health care providers?
4. Define your own scope of practice?
5. How do you integrate complementary and alternative medicine into your practice?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Chiropractice and Complimentary and Integrative Medicine.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Walker BF, French SD, Grant W, Green S. Cochrane Collaboration. Combined chiropractic interventions for low-back pain.
Available from the Internet at http://www.cochrane.org/CD005427/BACK_combined-chiropractic-interventions-for-low-back-pain (rev. 4/14/2010., cited 4/23/18).

Hawk C, Schneider M, Ferrance RJ, Hewitt E, Van Loon M, Tanis L. Best practices recommendations for chiropractic care for infants, children, and adolescents: results of a consensus process.
J Manipulative Physiol Ther. 2009 Oct;32(8):639-47.

Alcantara J, Alcantara JD, Alcantara J. The Chiropractic Care of Infants with Breastfeeding Difficulties. Explore (NY). 2015 Nov-Dec;11(6):468-74.

Todd AJ, Carroll MT, Mitchell EK. Forces of Commonly Used Chiropractic Techniques for Children: A Review of the Literature. J Manipulative Physiol Ther. 2016 Jul-Aug;39(6):401-10.

Pohlman KA, Carroll L, Hartling L, Tsuyuki R, Vohra S. Attitudes and Opinions of Doctors of Chiropractic Specializing in Pediatric Care Toward Patient Safety: A Cross-sectional Survey. J Manipulative Physiol Ther. 2016 Sep;39(7):487-93.

Hawk C, Schneider MJ, Vallone S, Hewitt EG. Best Practices for Chiropractic Care of Children: A Consensus Update. J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-68.

Newton. Wikipedia. Available from the Internet at https://en.wikipedia.org/wiki/Newton_(unit) (rev. 4/5/18, cited 4/24/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is the Developmental Outcomes of Patients with 22q11 Deletion Sequence?

Patient Presentation
A 5-year-old male came to clinic for his health supervision visit. He was transferring from a developmental preschool to kindergarten in the fall. The past medical history was significant for having 22q11.2 deletion sequence (22q11) after being diagnosed in the neonatal period because of congenital heart disease and dysmorphic facial features including hypertelorism, a small chin and ear abnormalities. In addition to successful cardiac surgery, he has had speech delays and bilateral grade II hydronephrosis that is being monitored. The family history was non-contributory. The pertinent physical exam showed a happy boy who had a weight parameter of 10%, height of 50% but was tracking. He had some speech problems but would talk right along with examiner. He overall seemed slightly immature for his age, but very pleasant. He had minor hypertelorism, small chin, and cupped ears. Pressure equalizing tubes were in place. His lungs were clear. His heart had a murmur consistent with his cardiac shunt.

The diagnosis of a child with 22q11.2 deletion going to kindergarten was made. The pediatrician reviewed each of the ongoing medical problems the boy had and the appropriate followup care. She then turned to the school issues. “He’s also getting speech therapy at preschool so will that be continuing at the new school too?” she asked. “We’re meeting with the school to make all of his transition plans. They have never had a child with this problem before but they seem willing to help. They can do speech therapy at school but I think he is going to need more than they can do and I’ve already identified someone who can do it after school. The school nurse already has his medical care plan updated from preschool. We probably are going to do a regular classroom for most of the day with the other part with the special education teacher. He may need an aide in the future too but I think we want to wait and see how things go. Part of it will depend on the other children’s needs in both classrooms and the teachers and paraeducators they may already have, ” the mother said. “It sounds like you have already been talking with them and have thought out a lot of what he will need to be successful next year. His needs are probably going change over time as you say, depending a bit on the other children and the teachers and resources the school has and how he grows and develops over time. I’d just make sure that you are in contact with the school, so that if something isn’t going as well, you all can work on it together. I’m happy to provide medical or other information to them if you would like. I know that his cardiologist and the geneticist can also do that if you want. Sometimes the specialty nurses will also go to schools to provide training for the staff or to answer questions the kids have. Let the school know that I’m happy to try to help if they want some help,” the pediatrician offered.

Discussion
22q11.2 deletion sequence (22q11) is the most common micro-deletion syndrome. Most deletions are de novo. It affects ~1 in 2000-4000 live births. As it is autosomal, it affects males and females equally. Childhood mortality is low and often associated with congenital heart defects. Its phenotypic expression is highly variable.

Some of the most common medical problems are:

  • Congenital heart defects especially conotruncal abnormalities
  • Palatal problems especially velopharyngeal incompetence and/or cleft lip/palate
  • Immunodeficiency especially T-cell lymphopenia, but also abnormalities of IgG production, autoimmune and humoral defects
  • Hypoparthyroidism resulting in hypocalcemia – may be evident also only at times of stress
  • Genitourinary abnormalities – renal agensis, hydronephrosis, absent uterus, cryptoorchidism, hypospadias
  • Feeding – gastroesophageal reflux, dysphagia, constipation
  • Dysmorphic features included hooded eyelids, hypertelorism, auricular or nasal abnormalities, small mouth and micrognathia. Cleft lip, cleft palate and Pierre Robin Sequence are also seen.

Learning Point
The cognitive and social phenotypes of patients with 22q11 has a wide variability in the overall development and trajectory of individual children because of genetics and the environment. In infancy and early childhood (0-4 years) studies show more gross motor and expressive language delays compared to siblings or other controls. In preschool to adolescence (4-18 years) learning difficulties and cognitive delays often occur.

The overall intelligence quotient (IQ) distribution for normally developing children is 85-115 with 100 being the mean. For children with 22q11 the distribution is still normal but is shifted with the mean falling in mid 70s (70-75). Most children (55%) have borderline intellectual disability (full score IQ 70-84), about 45% have mild to moderate intellectual disability (full score IQ 55-70) and a minority having severe intellectual disability. Children with 22q11 have better verbal reasoning than perceptual reasoning but again this varies with the individual. A large study of pooled cross-sectional data reported that “…between 8-24 years showed an average 7-point decline in [full score]IQ, driven by an average 9-point decline in [verbal]IQ and an average 5.1-point decline in [perceptual reasoning]IQ.” Again the trajectory for an individual is variable but potentially includes having a stable IQ trajectory, growing into a deficit as the patient falls behind peers, or an absolute decline.

Children are also at increased risk for developing psychiatric disorders over childhood, adolescence and adulthood including attention deficit hyperactivity disorder, autism spectrum disorder, anxiety, mood disorders and psychotic disorders particularly schizophrenia. Studies have found schizophrenia in up to 40% of patients with 22q11. Having 22q11 is one of the highest identifiable risk factors for schizophrenia; in comparison the general population’s life-time risk for schizophrenia is 1%.

Questions for Further Discussion
1. How are genetic disorders categorized? A review can be found here.
2. What does a child need to do to be ready for kindergarten? A review can be found here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Developmental Disabilities

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

McDonald-McGinn DM, Sullivan KE, Marino B, Philip N, Swillen A, et.al. 22q11.2 deletion syndrome. Nat Rev Dis Primers. 2015 Nov 19;1:15071.

Swillen A, McDonald-McGinn D. Developmental trajectories in 22q11.2 deletion. Am J Med Genet C Semin Med Genet. 2015 Jun;169(2):172-81.

Swillen A. The importance of understanding cognitive trajectories: the case of 22q11.2 deletion syndrome. Curr Opin Psychiatry. 2016 Mar;29(2):133-7.

Norkett EM, Lincoln SH, Gonzalez-Heydrich J, D’Angelo EJ. Social cognitive impairment in 22q11 deletion syndrome: A review. Psychiatry Res. 2017 Jul;253:99-106.

Shi H, Wang Z. Atypical microdeletion in 22q11 deletion syndrome reveals new candidate causative genes: A case report and literature review. Medicine (Baltimore). 2018 Feb;97(8):e9936.

Norkett EM, Lincoln SH, Gonzalez-Heydrich J, D’Angelo EJ. Social cognitive impairment in 22q11 deletion syndrome: A review. Psychiatry Res. 2017 Jul;253:99-106.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Should Fruits and Vegetables Be Washed?

Patient Presentation
A 6-month-old male came to clinic for his health supervision visit. He was doing well overall and his mother said that she was making her own baby food which he was taking well. She had already given him 3 different types of vegetables. “I want to give him the best food, and I am using a commercial food wash to clean the vegetables. But I’m worried that they still may not be getting clean, what do you recommend?” she asked.

The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters in the 10-50%. The neurological examination was normal and developmentally the child was sitting without assistance and had no head lag when pulled to a seated position. The diagnosis of a healthy male was made. “I don’t really have an opinion about using one of the commercial food washes, but I would recommend that if you use it, you follow the manufacturer’s recommendations especially. If it says to soak or rinse the food in a certain way or length of time, that is how it is supposed to be use and how it was tested,” he replied. “Usually washing foods thoroughly with a large amount of clean water is a good idea. Keeping the kitchen surfaces clean and separating how you prepare protein and raw foods such as fruits and vegetables is important. Most importantly, infants and young children should not be given foods that could be choking hazards and there are a few foods that aren’t recommended for home preparation for baby foods. We can go over those,” he said.

Discussion
Fruits and vegetables are great sources of nutrition and often are eaten raw. However, they can become contaminated during harvest, transportation, production, preparation and storage. Produce accounts for about half of all foodborne illness and about 20% of foodborne deaths. Outbreaks have been associated with all food sources including home gardens, local farms and large scale commercial food operations. Vegetables most associated with illness are leafy green vegetables, herbs and sprouts.

Learning Point
What are the best ways to keep raw fruits and vegetables safe?

  • “Wash your hands with hot soapy water before and after preparing food.
  • Clean your counter top, cutting boards, and utensils after peeling produce and before cutting and chopping. Bacteria from the outside of raw produce can be transferred to the inside when it is cut or peeled. Wash kitchen surfaces and utensils with hot, soapy water after preparing each food item.
  • Do not wash produce with soaps or detergents. [They are not designed for this and residual product may be retained on the food. Fruits and vegetables are also porous and may absorb the detergent.]
  • Use clean potable cold water to wash items. [Some people recommend distilled water as it has been purified and filtered to remove contaminants.]
  • For produce with thick skin, use a vegetable brush to help wash away hard-to-remove microbes.
  • Produce with a lot of nooks and crannies like cauliflower, broccoli or lettuce should be soaked for 1 to 2 minutes in cold clean water.
  • Some produce such as raspberries should not be soaked in water. Put fragile produce in a colander and spray it with distilled water.
  • After washing, dry with clean paper towel. This can remove more bacteria.
  • Eating on the run? Fill a spray bottle with distilled water and use it to wash apples and other fruits.
  • Don’t forget that homegrown, farmers market, and grocery store fruits and vegetables should also be well washed.
  • Do not rewash packaged products labeled “ready-to-eat,” “washed” or “triple washed.” [It could actually become contaminated from your home food preparation area.]
  • Once cut or peeled, refrigerate as soon as possible at 40ºF or below.
  • Do not purchase cut produce that is not refrigerated.”

Washing just before the food is eaten is a common recommendation.

Leafy green vegetables should be stored within 2 hours of harvesting or purchasing at 35-45°F. They can be soaked in cold water for a few minutes, then change the water and repeat. Dry in a colander, strainer or salad spinner. Another option is to soak the greens in 1/2 cup of vinegar and 2 cups of water followed by a clean water rinse.

In a study that tested blueberries soaked in distilled water for 1-2 minutes against 3 different commercial fruit and vegetable washes (that followed the manufacturers instructions) it was found that 1 commercial product was the same as the distilled water wash for removing pesticides, and distilled water was better than the 2 other washes tested. The University of Maine which conducted the study recommends to “[s]oak all produce for one to two minutes to reduce the risk of food-borne illness.” They also state that “You can also use… very clean cold tap water to clean produce instead of distilled water.”

The Iowa State University Extension offered a home recipe for a fruit and vegetable wash: “1 quart water, 2T. baking soda, 2 T. grapefruit or other acidic juice and 1 tsp cream of tartar. This mixture can be refrigerated for up to 2-3 weeks and is safe for human consumption.”

Overall properly washing or soaking in cold water will significantly reduce bacterial and other contaminants, and drying also aids this reduction.

Questions for Further Discussion
1. What foods should not be used for homemade baby food? Click here to review.
2. What are developmental milestones for solid food readiness? Click here to review.
3. What are the recommendations for starting peanut containing foods for children at risk for food allergies? Click here to review.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Food Safety and Foodborne Illness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

The University of Maine Extension. Bulletin #4336, Best Ways to Wash Fruits and Vegetables.
Available from the Internet at https://extension.umaine.edu/publications/4336e/ (rev. 2013, cited 4/13/18).

Marrs, Beth. Iowa State University Extension. Washing Fruits and Vegetables.
Available from the Internet at https://blogs.extension.iastate.edu/answerline/2014/01/13/washing-fruits-and-vegetables/ (rev. 1/13/14, cited 4/13/18).

University of Connecticut Extension. Wash Your Veggies (and Fruits)
Available from the Internet at https://blog.extension.uconn.edu/2014/03/12/wash-your-veggies-and-fruits/ (rev. 3/12/14, cited 4/13/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Is Considered a Minor Automobile Crash?

Patient Presentation
A 3-month-old female came to clinic about 2 hours after being a restrained passenger in a low-speed car accident. The patient was inrear-facing car seat in the back seat of a 2-year-old, sedan-style car. The mother was driving in a parking lot and had been rear-ended by another car. The mother stated that the left rear light area had been damaged but the bumper was intact. The other car had right front light damage and was otherwise okay. Both drivers had no injuries, no airbags deployed in either car, and both cars were drivable. The infant had seemed slightly fussy after the incident and did not feed as well as usual so the mother wanted the child examined. The mother denied any other problems such as loss of consciousness. The past medical history showed a full-term infant who had received appropriate preventative care.

The pertinent physical exam revealed a smiling infant with normal growth parameters and vital signs. HEENT showed that the anterior fontanelle was patent and not bulging. Skin showed no bruising. Her neurological examination was normal. The diagnosis of a healthy 3 month old who had been in a low-speed car accident was made. The mother was counseled that the infant appeared well at this time and that this seemed to be a low-speed accident, therefore watchful monitoring was called for. “I’m not sure why the baby didn’t eat as well but she appears well now and I think you can just watch her as this sounds like a low-speed accident. Let’s look at the car seat you have here and see if it has any information about when to replace it after an accident too,” the pediatrician counseled. The car seat did not have any noticeable damage but did have a notice that it should be replaced if it was in a crash when examined by the pediatrician. “You should always follow the manufacturer’s recommendations and in this case, I would replace the car seat even though this seemed to be a low-speed collision,” she remarked. Later she was reviewing the encounter with the medical student who had accompanied her during the visit. The medical student asked at what speeds airbags deploy. “I’m not entirely sure but it is lower than you think. We should try to find the answer,” and they went to a computer to check the Internet for more information.

Discussion
Airbags are supplemental (not primary) safety devices in motor vehicles that are intended to prevent injuries mainly to the head, neck, and torso. They are designed to provide the greatest protection when the occupant is seated properly and wearing a seat belt properly. Front airbags are designed to inflate within 50 milliseconds of impact in a moderate to severe crash. They usually will deploy for belted occupants at speeds of 16 miles/hour (mph) or more, but with newer sensors and algorithms will deploy at lower speeds if they detect unbelted occupants (i.e. 10-12 mph). Forward airbags will also deploy for impacts in other vehicle locations if there is sufficient forward motion of the occupant detected. In the US front airbags have been required since the 1999 model year.

Side airbags are designed to inflate for side impacts or if parts of the vehicle begin to intrude in the passenger compartment. Head protection is considered of primary importance, but other airbags offer more pelvis or torso protection. As there is a smaller space between the vehicle’s side and the occupant, the airbags need to deploy quicker usually within 10-20 milliseconds of impact. Side airbags are not necessarily required in the US but are often used to meet the standards for head and torso protection required for all occupants.

Airbags may deploy from a variety of locations depending on the model. Steering wheel, passenger front panel, ceiling, doors, and seat backs are common locations for airbags which may be marked with “SRS” or “Airbag”. Airbags should be replaced with “OEM” or original equipment manufacturer replacement parts after they have been deployed. Recalled airbags should be replaced as soon as replacement parts are available by a qualified repair shop associated with a new-car dealership.

Other airbags include knee airbags, inflatable seat belt airbags, between seat airbags, and external hood airbags. In some countries airbags integrated into motorcycles are available. There is also a bicycle helmet that has an integrated airbag too.

National Highway Transportation Safety Administration (NHTSA) estimates that 44,869 lives have been saved by frontal airbags and 2252 saved because of side airbags up to 2015. Airbags can cause injury because they must inflate quickly. Therefore, drivers and front passengers should be as far back from the steering wheel and passenger instrument panel as they can: at least 10 inches from the occupant’s chest. Pregnant women, especially in their last trimester of pregnancy, if they cannot be positioned correctly are recommended to not drive. Shorter drivers may be able to slightly recline the seat or may need pedal extenders. A rear-facing car seat should never be put into a front passenger seat with an airbag as it positions the head to close to the airbag. All children should be placed in the rear seat. Children over 13 may sit in the front seat, properly belted in and positioned, but still the safest location is the middle or rear of the vehicle. Young children who must routinely be transported in the front seat can seek help from their car manufacturer or NHTSA regarding airbag options.

Learning Point
The National Highway Transportation Safety Administration (NHTSA) defined a minor motor vehicle crash and all criteria must apply as:

  • “The vehicle was able to be driven away from the crash site.
  • The vehicle door nearest the car seat was not damaged.
  • None of the passengers in the vehicle sustained any injuries in the crash.
  • If the vehicle has air bags, the air bags did not deploy during the crash; and
  • There is no visible damage to the car seat.”

Always follow the manufacturer’s instructions. A car seat should never be used that has been involved in a moderate to severe crash.

A moderate to severe crash is defined as the “equivalent to hitting a solid, fixed barrier at 8-14 mph or higher. (This would be the equivalent of striking a parked car of similar size at about 16-28 mph or higher.)

Questions for Further Discussion
1. What are the recommendations for use of car seats for various ages and sizes of children?
2. What are the recommendation for bike helmet use and bicycling safety for children?
3. What summer and winter safety guidance should be offered to families? For summer safety click here; for winter safety click here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Motor Vehicle Safety.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

NHTSA. Air Bags.
Available from the Internet at https://www.nhtsa.gov/equipment/air-bags (cited. 4/13/18).

Insurance Institute for Highway Safety. Highway Loss Data Institute. Airbags.
Available from the Internet at http://www.iihs.org/iihs/topics/t/airbags/qanda (cited 4/13/18).

NHTSA. Car Seat Use After a Crash.
Available from the Internet at https://www.nhtsa.gov/car-seats-and-booster-seats/car-seat-use-after-crash (cited 4/13/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa