Patient Presentation
A 12-month-old female came to her health supervision visit. She was doing well and the mother had no concerns other than the eczema rash that seemed to be worsened since the winter weather started. The mother had been using petroleum jelly on her face once in a while. The past medical history was non-contributory. The pertinent physical exam showed a smiling, early walker in the office who pointed and said 1 word sentences. Her growth parameters were in the 50-90%. Her skin examination showed general xerosis of the skin, with moderate reddening of her cheeks and a couple of other spots on her extremities.

The diagnosis of healthy female with eczema was made. The pediatrician recommended to use the petroleum jelly or other emollients frequently and re-counseled the mother about when and how to use steroid medications. “I usually recommend that you put a jar or tube by the winter clothing too so you can put some on to protect her face in the winter too,” he said. After the infant’s vaccinations, he returned to the room to give the parent a child care health form and noticed the infant was in a bulky coat when in her car seat attached to the stroller. “I think that you need to take the coat off her and then use it like a blanket. The problem is that the straps may not be tight enough and she could come out of the seat in an accident,” he said. He then had the mother take the child’s coat off and showed her how the straps were too loose. “You can get the straps tight now and then put the coat on top. That way she stays safe and warm. Plus if she gets too hot you can take the coat off her too,” he noted.

Discussion
During the wintertime, everyone needs to bundle up to stay warm but too much clothing or using it improperly can cause problems.

General rules for infant and children’s clothing is to have them wear one more layer of clothing than the adult is comfortable wearing in the same environment. Premature infants may need a second layer. (In hot weather a single layer for infants and children is enough.)

Dress the children in thin, multiple layers. Here are a couple of examples:

• Infant
  • Undershirt and diaper, socks or booties
  • Pajamas or dressing gown
  • Blanket sleeper, sleep sack or receiving blanket
  • *Hat and mittens
  • *Coat or blanket
• Older child
  • Underwear/diaper and socks
  • Long sleeve body suit, leggings, long underwear
  • Pants and thermal shirt or sweater
  • Thin fleece jacket
  • *Hat and mittens
    *Coat or blanket

*Top layers should be removable if in a car seat and as the car warms up, the appropriate clothing can be removed.

Types of clothing that are easier to use include:

• Clothing with front fasteners
• Stretchy material to allow the child to move and to make un/dressing easier
• No strings, ribbons, yarn or other decorations that could cause choking
• Pack extra clothing – if something gets wet then you have a back up. Extra mittens are important if you have a thumb sucker

A review of winter safety can be found here.

A review of fire safety (fires often occur in winter) can be found here.

Learning Point
In general, nothing should be between the child and the harness in the car seat, or the child’s back and the car seat. Use the car seat cover that comes from the manufacturer for the specific car seat. Do not use other items that did not come with the car seat from the manufacturer as they usually are not car crash tested.

Bulky clothing can cause the harness straps to not be tight enough. They can look tight but really aren’t. In an accident the force will compress the clothing and then there may be enough room for the child to slip through the harness straps and cause injury or ejection from the seat.
In general the child should be put into the car seat, harness adjusted properly and then the coat put on over the harness like a blanket. A blanket or poncho can also be used. Remember to keep the blanket away from the child’s face.

Test outer clothing to see if it is too bulky to wear by:

• Put the child in the car seat and adjust the straps
  • Strap height should be at or below the shoulders for rear-facing car seats
  • Strap height should be at or above the shoulder for forward-facing car seats
  • The chest harness clip should be at nipple/armpit height
  • The straps should lie smoothly across the shoulders, down the body and across the hips
  • Do the pinch test. Around the shoulder, try to pinch the shoulder straps. The straps should be tight and someone cannot “pinch” any of the straps.
  • One finger should be able to fit underneath the strap between the strap and child to provide some comfort but not be loose. No slack in the harness.
• Take the child out of the car seat and take off the child’s coat
• Put the child back into the car seat with the coat off
• Recheck the strap adjustment
  Re-do the pinch test. If there is any strap that can be pinched then the child cannot use the coat under the car seat harness straps.
• If the coat does not fit, then put the child into the car seat with a properly adjusted harness and then the coat put on over the harness like a blanket as noted above.

Teens and adults should also look at their own clothing and make sure that bulky clothing does not change the proper seat belt positioning. The seat belt should lie flat directly on the body across the upper thighs. The shoulder belt also should be directly on the body and come across the torso and across the shoulder. Unzipping/buttoning a coat usually allows the seat belt to be correctly adjusted directly on the body. The “ends” or sides of the open coat should also be adjusted to not impede the movement of the seat belt.

Other points:

• Start the process of getting into the car early giving time for uncooperative children, or misplaced items
• For infants, bringing the removable cradle inside keeps the cradle warm and the infant will lose less body heat than if placed into a cold car. The infant can be correctly placed into the cradle in a warm location.
• Similarly, keep blankets, ponchos etc. inside before bringing them to the car for infants and older children.
• The car seat installation should be rechecked often. The car seat should not move more than 1 inch from side to side when correctly tightened. They also should be at the proper reclining angle. Use the tethers correctly and use all of them including the top tether.
• Always double check that all children are out of the car before leaving it. This is a safety measure for both the winter and especially the summertime when temperatures can become quickly excessive in a closed car.

Questions for Further Discussion
1. What are some of the common winter safety problems? A review can be found above.
2. What summer safety tips do you give parents? A review can be found here.
3. What are the recommendations for when a child should be moved from one type of car seat into a larger one? When can a child be moved into a regular adult seat belt?

Related Cases

Disease: Winter Clothing | Car Seats | Motor Vehicle Safety | Child Safety

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: General Pediatrics

Age: Toddler

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: Motor Vehicle Safety and Child 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.

10 Dangerous Mistakes Parent Make When Using Car Seat Strap Covers. Consumer Reports. Available from the Internet at https://www.consumerreports.org/cro/news/2013/11/10-dangerous-mistakes-parents-make-when-using-car-seats/index.htm (rev. 11/4/13, cited 11/7/17).

Winter Care Seat Safety Tips from the AAP. HealthChildren.org. Available from the Internet at https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Winter-Car-Seat-Safety-Tips.aspx (rev. 12/14/15, cited 11/7/17).

The Dangers of Winter Coats and Car Seats. Consumer Reports. Available from the Internet at https://www.consumerreports.org/cro/news/2012/12/winter-coats-and-car-seats-keeping-your-child-safe-and-warm/index.htm (rev. 2/25/16, cited 11/7/17).

Dressing Tips for Your Baby. Healthchildren.org. Available from the Internet at https://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/Dressing-Your-Newborn.aspx (rev. 6/17/16, cited 11/7/17).

Young SD. Is your child’s coat too bulk to be worn in a car seat?. ConsumerAffairs. Available from the Internet at https://www.consumeraffairs.com/news/is-your-childs-coat-too-bulky-to-be-worn-in-a-car-seat-010417.html (rev. 1/4/17, cited 11/7/17).

Daniels H, Laliberte M. You should never put your child in a car seat with a puffy coat – here’s why. Business Insider. Available from the Internet at http://www.businessinsider.com/why-you-should-never-put-your-child-in-a-car-seat-puffy-coat-2017-10 (rev. 10/30/17, cited 11/7/17).

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