A 6-month-old male came to clinic for his health supervision visit. He had generalized hypotonia of unknown cause and was continuing to be evaluated and monitored by pediatric neurology and genetics.
The past medical history showed a full-term male born without complications. Evaluation to date had included negative head imaging, normal creatinine kinase, and genetic evaluation including Prader-Willi testing.
He had been evaluated by the developmental disabilities team and was receiving some physical therapy through the school district’s early intervention program. The physicaltherapist was happy with his progress.
The family history was significant for a paternal cousin who had a child die in infancy of an unknown cause.
The pertinent physical exam a smily, interactive male with growth parameters in the 25-90%.
He had mild but noticeable hypotonia of his trunk. He held is head fairly well once he was placed into a position, but had more problems with transitioning between positions.
He transferred objects but this had a rudimentary quality to it. Cranial nerves, and strength were normal. He had no early primitive reflexes noted.
The rest of his examination including his skin was normal.
The diagnosis of an infant with hypotonia receiving appropriate developmental services was made.
His pediatrician asked how his car seat was fitting as part of his health supervision visit. The parents said that there were no problems currently and they helped support his head with rolled up towels placed to each side as they had been shown to do by a car seat technician.
The pediatrician reminded the parents that he would need to be in the rear-facing car seat until at least 2 years of age.
However, he also told them that because the child also had hypotonia, it might be necessary to keep the child rear-facing to help support his body until an older age or need a special car seat to meet his needs.
He said that they would discuss it more at the child’s 12 month health supervision visit and possibly consult with one of the certified car seat technicians that were available through the local police department.
Every pediatric health care provider should be familiar with car seat safety basics.
This includes where seats are best located in a vehicle – back seat of the car or closest to the center of the car
What type of seats are available and when can a child use each type*:
- Rear-facing – used for infants up to 2 years of age. These have a 3 or 5-point harnesses that hold the child in the car seat. It is safest to be rear-facing as long as possible.
- Forward facing or convertible car seats that are used forward facing – used by toddlers > 2 years of age and up to approximately 40 pounds. These have a 5-point harnesses that hold the child in the car seat.
- Booster seat – these are used for preschoolers/school age children who are forward facing. They boost the child upward in the seat but use the vehicles own shoulder and lap belt system to secure the child. A booster seat for children > 40 lbs and 40 inches tall should be used until the vehicle seat belt fits well. High backed booster seats are recommended if possible.
- Vehicle seat belts – used by older school age children and teenagers, generally for children > 80 pounds and > 4 foot 9 inches tall.
*this case was updated on 11/18/17 to confirm to the the 2011 AAP recommendations
Pediatric health care providers should also be familiar with other common venues where child car seats are used such as during shopping or airline flights.
Infant car seats that have lock into shopping carts or infant car seats that are built-in are extremely dangerous and are not recommended. Instead, families should use a stroller or baby backpack during shopping.
Federal Aviation Administration approved car seats are recommended for children up to 4 years of age during airline flights. After age 4, they should be restrained with the lap belt. Booster seats are not allowed.
Car seats should only be used for travel, not for sleeping, feeding, playing, etc.
Every child should be transported in the safest way possible. Children with special health care needs (CSHCN) need accommodations to travel safely. The specific needs of each child should be evaluated and an appropriate transportation plan made.
This plan needs to be re-evaluated as the child grows and/or if the medical needs change.
Certified car seat technicians can assist healthcare providers and families with problem solving regarding car seat installations and fittings.
Car seat technicians receive special classroom and installation training in using car seat effectively and safely. After initial training, they must continue to update their knowledge and skills through continuing education to maintain their certification.
Local certified car seat technicians can often be found through hospitals, police departments, and various social service agencies. They can also be found through the National Highway Transportation and Safety Administration (NHTSA) website at http://www.nhtsa.dot.gov/people/injury/childps/contacts.
Many local businesses and agencies sponsor car seat inspections. Lists of local inspections can be found at http://www.seatcheck.org or by telephone at 866-SEATCHECK.
The SafeKids Coalition works to improve child safety including car seat safety. Local chapters can be found at http://www.usa.safekids.org/tier2_rl.cfm?folder_id=3120.
Another option is to contact the National Center for the Safe Transportation of Children with Special Health Care Needs at http://www.preventinjury.org or by telephone at 800-620-0143.
General concepts regarding children with special health care needs CSHCN include:
- The safest place for any child to ride is the back seat. If there are no other options than to transport a CSHCN in the front seat, then the airbag system if present MUST be switched off because of the risk of injury. This may require permission from the NHTSA who can be contacted at http://www.nhtsa.dot.gov or by telephone at 888-327-4236.
- Children with special health care needs may need special restraint systems (such as a car bed) or need to have modifications made to regular restraint systems (often positioning changes).
- Special systems need to be evaluated with the help of a certified car seat technician and may also require the services of other professionals such as rehabilitation specialists. To find a local qualified driver rehabilitation specialists, contact a local rehabilitation center or the Association for Driver Rehabilitation Specialists at http://www.driver-ed.org by telephone at 800-290-2344.
- In certain circumstances, professional transportation such as an ambulance may be necessary (for example a tall child in a cast). Adapted vehicles for family use or use for regular transportation needs such as traveling to school may also be necessary.
- A car seat and/or harness should never be altered. Even simple alterations can change the safety and performance of car seat. Any contemplated changes should be discussed with a car seat manufacturer.
- For positioning the child in the center of the seat folded up blankets, towels, or foam can be used. To prevent sliding down into the seat, a smaller cloth like a wash cloth can be rolled up and placed between the child’s bottom and the crotch strap (on a 5 point harness system).
Nothing should be placed under or behind the actual car seat/restraint.
- Necessary medical equipement should be secured in the vehicle to prevent it from becoming a projectile in the event of an accident. Car seat technician can also assist with ideas to secure medical equipment.
- If possible, have a separate person monitor the child in their seat during travel to monitor the child and necessary medical equipment.
- CSHCN should have a travel pack which includes emergency supplies such as replacement tracheostomies or gastric tubes, 2 times the amount of oxygen and batteries thought necessary for the trip, extra medications, a personal health record to help emergency personnel should there be an accident.
Questions for Further Discussion
1. When does a car safety seat need to be replaced?
2. In what situations can travel vests be used safely?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for these 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.
American Academy of Pediatrics. Car Safety Seats: A Guide for Families 2008.
Available from the Internet at http://www.aap.org/family/carseatguide.htm (rev. 2008, cited 1/14/2008).
American Academy of Pediatrics. Transporting Children with Special Needs.
Available from the Internet at http://www.aap.org/publiced/BR_SpNeedsCarSeats.htm (rev. 3/2007 , cited 12/13/2007).
American Academy of Pediatrics. Transporting Children with Special Needs.
Available from the Internet at http://www.aap.org/healthtopics/carseatsafety.cfm (cited 1/14/2008).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Gretchen Vigil, MD
Associate Professor of Clinical Pediatrics, University of Iowa Children’s Hospital
January 28, 2008