Housekeeping Details

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Housekeeping Details
An Update on Newborns in Car Safety Seats and the
Infant Car Seat Challenge Test

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Todays 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

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Child Passenger Safety
What we know, what we use, and what we do has
changed dramatically!
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Weve Come A Long Way for Baby!
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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

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Car Bed Options for Infants Who Must Lie Flat
Dream Ride SE 5 20 lbs 19 26
Angel Ride Birth 9 lbs lt21.5
Hope 4.5 35 lbs 13 29
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Infant Car Seat ChallengesWho, What, When,
Where, Why and How?

• Natalie Davis, MD, MMSc
• Assistant Professor of Pediatrics
• University of Maryland School of Medicine
• Division of Neonatology

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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

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Why? Who?

• Why do this test? (History of the ICSC)
• Who should be tested?

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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 lt37 weeks
• 90-120 minutes, or length of car ride home,
  whichever is longer
• No guidelines for failure criteria

Bull MJ, et al. Pediatrics. 2009 Willett.
Pediatrics. 1986 and 1989 Salhab. J Pediatr. 2007
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Local Statistics

• Premature born lt37 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

http//en.wikipedia.org/wiki/FileMaryland_in_Unit
ed_States.svg
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Who?

• All babies born lt37 weeks gestational age (GA)
• Overall failure rate of 4.3
• 2.4 in infants born early preterm lt34 weeks GA
• 5.6 in late preterm born 340/7 366/7 weeks
  GA
• Who else?
• Full term babies born lt2.5kg
• 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
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ICSC Whats 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 lt2.5kg? 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?

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What?

• What failure guidelines should be used?

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Results

• Following AAP Guidelines
• 11 did not perform ICSCs
• 17 did not test all infants born lt37 weeks GA
• 45 tested for lt90 minutes
• Additional Criteria
• 45 included Low Birth Weight as a testing
  criterion, testing all babies born lt2.5kg
• No consensus on failure criteria for bradycardia
  or desaturations

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

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Suggested Failure Criteria

• Apnea gt20 seconds
• Heart Rate lt80 beats per minute for gt10 seconds
• Saturation lt90 for gt10 seconds
• Respiratory distress not improved with proper
  positioning
• Canadian Paediatric Society
• Two episodes lt88 for gt10 seconds

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When?

• What to do when a baby fails?

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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

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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
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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

http//injury.research.chop.edu/sites/default/file
s/car_bed.jpg
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Safety Car Seat vs. Car Bed

• 150 VLBW babies born lt37 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

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
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Failed ICSCwhat 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 12-24 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

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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 infants own semi-reclined
  car safety seat
• At term equivalent (40 weeks) or 2-4 weeks after
  discharge
• Repeat via pediatricians office or at pediatric
  pulmonologists office
• Test in outpatient clinic
• Test as inpatient with polysomnography

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Where?

• Where is future research focusing?

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Future Research

• Incidence and risk factors for failure of the
  ICSC in full term, low birth weight (lt2.5kg)
  babies
• Recorded oximetry prior to the ICSC to predict
  failure
• Inserts to improve oxygenation in the car seat
• ICSC in all infants?

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How?

• How should we counsel families?

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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

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Best Practice for ICSC

• Test can be done any time of night or day, but
  make sure parents are aware
• Perform gt24 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 familys actual car seat

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Suggested Failure Criteria

• Apnea gt20 seconds
• Heart Rate lt80 beats per minute for gt10 seconds
• Saturation lt90 for gt10 seconds
• Respiratory distress not improved with proper
  positioning
• Canadian Paediatric Society
• Two episodes lt88 for gt10 seconds

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Failed ICSC

• Assess for fit of infant in car seat,
  appropriateness of positioning
• Update family
• Perform repeat ICSC gt 12-24 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

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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

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THANK YOU!-Natalie Davisndavis_at_peds.umaryl
and.edu
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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 babys 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

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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 agencys CPS policies and
  procedures
• Youth/pre-driver curriculum and
  train-the-trainer sessions

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Our 2009 training DVD for healthcare providers
One of our free posters
(11 x 30)
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MD KISS Services

• Presentations/Trainings
• Car Seat Check-Up Events
• Skype Virtual Inspections/Assistance
• Car Seat Assistance Programs
• Information Referrals

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Kids In Safety SeatsContact Info

• Helpline 800-370-SEAT (7328)
• Email dhmh.kiss_at_maryland.gov
• Web www.mdkiss.org
• Skype mdkiss2

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