Answers to "Mistake Monday" 3/15/10

ANSWERS: 
(please see bottom of page for teaching points & a printable version of the American Academy of Pediatrics' tips for positioning newborns and preemies in car seats)

MISUSE
- **The baby's chin is on his chest**
- There is an aftermarket infant head support used (the white product behind the child's head)
- Harness straps are too loose
Note: The buckle hardware resting on the infant's abdomen is not dangerous.

INJURY PATTERNS ASSOCIATED WITH THE MISUSE

The Baby Stops Breathing!
Unlike our other mistake Mondays, the biggest mistake in this picture - the infant's chin on his chest - is likely to harm the baby without a crash even occurring.  The recent recall of thousands of infant slings highlighted this same issue - that newborns can stop breathing if their chin rests on their chest.  

Small infants have very short necks, so when the neck flexes the chin falls forward onto the chest and the infant's own chest presses on the chin.  Until babies are at least a month old, the connection between the jaw (mandible) and the skull bones (temporal bone) is not formed, which means that pressure upwards and backwards on the jaw, as happens when the chin rests on the chest, pushes the jaw backwards.  The tongue sits inside the jaw bone and is pushed into the back of the mouth and onto the soft palate.  The tongue thereby completely blocks the flow of air from the nose into the lower parts of the airway.  Babies ONLY breathe through their nose (except when crying and gasping).  Babies can not switch and breathe through their mouth as older kids and adults can - so if the flow of air is blocked between the nose and the lower airway, the baby will stop breathing.

The ironic part is that U-shaped infant head supports, which by the way have no safety regulations or crash testing that they must conform to, actually make matters worse.  Head supports, like the one in the picture, which try to prevent the infant's head from turning to the side often make matters worse.  The back of an infant's head (occiput) is very prominent.  Forcing the head to rest straight forward, as these infant head supports try to do by preventing the head from turning to the side, only encourages the head to fall forward and the chin to rest on the chest.  Having the baby's head turned slightly to the side (but with the chin far above the chest) is a much more natural position for the infant's large head.

TEACHING TIPS -  

3 Steps to Keeping an Infant's Head in a Safe Position 

1.  Make sure the harness straps are snug

•      Snug straps keep the body & head straighter by preventing the baby from slumping over
•      Some infant seats are too big for preemies & small newborns - check to see if yours is appropriate here

2.  Make sure the car seat is as reclined as the manufacturer allows

•  For most infant seats, the most reclined the seat can be is so that the part where the infant's head & back rests makes a 45 degree angle to the ground.   Most seats have a level indicator - be it a bubble level, pendulum gauge, or just a straight line - to help you know how reclined the seat can be when in the vehicle.
• Image from AAP - showing a rolled towel under the base to help acheive the 45 degree angle

3.   Do NOT place anything behind or in front of the baby's head & neck

• Do NOT use an infant head/body positioner that did not come with the car seat.  Such "aftermarket" products are not tested for safety - either in a crash or just general safety - and often make the situation worse by tipping the head forward and changing how the straps fit on the child's body.  In addition, the use of an "aftermarket" product in a car seat will void the car seat manufacturer's warranty.  Please see the bottom of this post for more specific information from each car seat manufacturer - along with an easy-to-print handout on the topic.
• Most infant seats come with removable infant head rests. Of the infant car seats currently on the market with removable head rests, all can be safely removed EXCEPT for the one in the Britax Chaperone (as this one is part of the side impact protection of the seat).  Except for the one in the Britax Chaperone, these infant head rests are NOT safety features of the seat - so if you think that the head rest is either not improving, or worsening, the infant's head position we would recommend removing it. 
• If you do not like how it looks with the baby's head turned to the side, you can roll two small diaper cloths and place them alongside the baby's head.

The American Academy of Pediatrics issued an updated Clinical Report on Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge - which has great tips for positioning newborns of all sizes in car seats.

References:
Bull MJ.  Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge. Pediatrics. 2009 May 5; 1424-1429.

Tonkin SL. Airway of babies in car seats. The New Zealand Medical Journal. 1998 Sep 25;111(1074): 372

Aftermarket Products: What Do The Car Seat Manufacturers Think of Them??

**For an easy-to-print handout of this information, click here***

Fleece bunting - NOT SAFE for the car seat

You've seen them - the infant head inserts, the fleece buntings, the shoulder strap covers - they line several aisles in most Babies R Us. They are made to be used with the car seat - but didn't come with the car seat.

Did you know that unlike your child's car seat which must pass rigorous crash testing, these "aftermarket products" have no crash testing or other crash safety standards they must meet? Most parents buy these products thinking they will make the car seat safer and more comfortable for their baby - not realizing that these products usually turn a safe car seat into an unsafe one.

But don't take our word for it, here is what the car seat manufacturers have to say about aftermarket products. These excerpts were taken directly from the child safety seat instruction manuals.

* Baby Trend

o Do Not dress your child in bulky clothing or other garments that will hinder the harness from being snug around your baby and properly latched between your child's legs.

o Accessory products for use with the Safety Seat are acceptable for use provided that they do not interfere with the harness assembly, or the proper adjustment of the harness such that it remains tight on the child's shoulders at all times. Thick, soft, or other compressible material in excess of 1/4 inch thick should not be placed behind or under the child or between the child and harness straps. Examples of accessory products are head support pillows or rolled blankets to add additional head support.

* Britax

o The use of non-Britax Child Safety, Inc. covers, inserts, toys, accessories, or tightening devices is not approved by Britax. Their use could cause this restraint to fail Federal Safety Standards or perform worse in a crash. Their use automatically voids the Britax warranty.

* Chicco

o NEVER use clothing or blankets that interfere with fastening or tightening the harness. An unsecured child could be ejected in a sudden stop or crash! To keep child warm, place a blanket over child and restraint AFTER you have properly secured child in harness.

o DO NOT use any accessories, pads or products supplied by other manufacturers with this Child Restraint. Items not tested with this restraint could injure your child.

* Dorel (Maxi Cosi, Cosco, Eddie Bauer, Safety 1st):

o Dorel Juvenile Group does not recommend the use of any child restraint accessories except those recommended by DJG.

* Evenflo

o In cold weather, DO NOT dress the child in bulky clothing like snowsuits if the child is riding in a child restraint. Bulky coats/ snowsuits make it difficult to properly tighten the harness to the child, which may allow the child to be ejected from the restraint during a crash.

* Graco

o DO NOT use accessories or parts other than those provided by Graco. Their use could alter the performance of the car seat.

* Orbit 

o Do not modify your Infant Car Seat or Base. Only use products and accessories approved by Orbit Baby to ensure the safety of your child. This limited warranty does not apply to: defects resulting from use with covers, inserts, accessories, tightening devices, or other components not supplied by or expressly approved in writing by Orbit Baby.

* Peg Perego

o Use only approved parts. Use of unapproved parts can affect the safety of the car seat and cause serious injuries in an accident.

* Sunshine Kids

o Using any non-Sunshine Kids product with this restraint; or any product not specifically approved by Sunshine Kids for use with this restraint is not allowed. Use of such products voids manufacturer's warranty and may seriously impact the products ability to perform properly in an accident.

A chilling reminder why kids need car seats on EVERY trip.

Sometimes you have to try and make lemonade out of lemons.  Perhaps the senseless deaths of so many people in this crash will convince just one parent of the importance of using a car seat on every trip.  

Going in someone else's car - and tempted to not bring your child's car seat? 

Yesterday, 13 members of a family were traveling together to a wedding. The unbelievably horrific happened when a tractor trailer crashed into them.  A baby who was held by relatives died in the crash.  The silver lining to this story - the 2 children who were riding in car seats were the only survivors. 

Always use a car seat - on EVERY trip.

 Image: (C) (AP Photo/Daily News, Joe Imel)

 

Riding in Style (and safely too!)

Silver may be the new black, but safety is the best statement to make. 

This 3 year old is 34 pounds and is riding REAR-FACING and in style (check out the silver toe-nail polish!)

 

Monday's Mistake - can you spot the mistake/s in the picture?

As you may have guessed, it isn't enough to be able to spot the misuse (I have picked some obvious examples, I realize) - but rather it is critical to be able to explain why it is a problem AND solutions to correct it. 

As a pediatrician working in a NICU (Neonatal Intensive Care Unit), the picture of this newborn is near and dear to my heart.  Sadly, the misuse shown in this picture is probably one of the most common in the newborn age group - and represents a significant risk to this baby's health and safety.

What mistakes can you identify (besides the obvious of the straps not being snug)?
For bonus points, what type of injury pattern might you see as a result of this misuse? 

Post your answers below - and I will post the correct answer on Tuesday.

Please note: This photo was not staged.  This photo was taken by a real parent just like you who didn't know that they were using the seat improperly.  9 out of 10 car seats are used incorrectly - don't let your child ride at risk.   If you are in the NYC or Baltimore areas, email us at info@thecarseatlady.com to schedule a private car seat installation lesson - otherwise, visit www.seatcheck.org to find someone in your area to teach you how to install your seats properly.

Answers to "Mistake Monday" 3/8/10

ANSWERS: 
(please see bottom of page for teaching points & printable tip sheets for parents)

MISUSE
- Girl in front: Shoulder belt under her arm
- Girl in back: Lap belt high on her belly (note: the shoulder belt rubbing her neck is not likely to cause injury in a crash)

INJURY PATTERNS ASSOCIATED WITH THE MISUSE

HEAD AND NECK INJURIES
The head is the most important part of the body to protect.  In a crash, the head can potentially hit hard structures in the vehicle - like the seatback of the front seat, the window, the door frame, etc - all of which can cause significant injuries to the brain and upper spinal cord.  The best way to protect the head is to try and prevent it from hitting anything during the crash.  

Placing the shoulder belt under the arm leads to an increased risk of head and neck injuries as the head travels farther forward than it would with the shoulder belt properly positioned across the collar bone.  

These three pictures, taken from a 30mph crash test, show how far forward the head of this 6 year old crash test dummy moves.  The green line marks the farthest the head moved forward when the dummy was properly restrained in a high back booster.  The yellow line marks the farthest the head moved forward when the dummy placed the shoulder belt under its arm (and was not in a booster).  The red line marks the farthest the head moved forward when the dummy placed the shoulder belt behind its back (and was not in a booster).  Notice how the dummy's head strikes the seatback in the third photo - and in a smaller vehicle (or a large vehicle where the driver moves his seat back all the way) the dummy with the shoulder belt under the arm would also hit its head on the seatback.

 Photo: 6 y/o dummy properly restrained in high back booster - Copyright UVA 

 Photo: 6y/o dummy with shoulder belt under its arm -  Copyright UVA

Photo: 6y/o dummy with shoulder belt behind its back - head strikes the seatback - Copyright UVA

SEAT BELT SYNDROME
The lap belt is designed to rest on the strong hip bones.  The soft belly is not strong enough to withstand the forces of a crash.  Should the lap belt slide up over the hip bones and into the soft belly, the lap belt can cut through the belly all the way to the spinal cord causing injuries to the spinal cord and the soft organs in the belly.  This pattern of injuries is known as "seat belt syndrome" and is seen most often in 4-10 year olds who are not riding in booster seats - although it can be seen in anyone when the lap belt rests on the belly.

TEACHING POINTS
A shoulder belt that rubs the neck will not injure a child in a crash - but since it is uncomfortable for the child, kids often place the belt under the arm or behind the back.  Never allow a child to place the shoulder belt behind the back or under the arm - this only increases the child's risk of severe head and abdominal injury.

A lap belt that rides up into the belly can cause significant injuries to the soft organs in the belly (liver, spleen, bladder, intestines, kidneys) in addition to breaking the lower spinal cord causing paralysis.  Placing the shoulder belt behind the back or under the arm increases the risk for these belly and spinal cord injuries as without the shoulder belt to properly hold the upper body back, the body naturally folds at the waist (close to the belly button) which allows the lap belt to ride up over the strong hip bones and onto the waist, thus causing injury.

Does your child's booster make the belts fit well?

• The lap belt should rest low and flat on the tops of the child's thighs (nowhere near the belly button).  
• The shoulder belt should rest between the neck and the shoulder.

RESOURCES FOR PARENTS 
Are you a pediatrician or CPS Tech who wants to give a parents some more information on booster seats?  Here are several fantastic tip sheets that are free to reproduce.  Links will open as a PDF document.

• “Boosters Are For Big Kids” - This covers the 5-Step Test with pictures showing belt fit with and without booster.  Also available in Spanish.  
• Booster Seats and Other Products for Children Over 40 Pounds - Guidelines for size, fit, and usage; list of belt-positioning boosters with weight ranges and features.  Also available in Spanish.
• For Your Family: Belt Positioning Booster Seats.  Also available in Spanish. 
• Fotonovella (in Spanish) - designed as an educational tool to promote booster seats among Latino communities.

Makes My Day!

Received this email today and had to share - TOTALLY MADE MY DAY!: 
When my son was 11 months in 2007 Emily (fellow NYC car seat lady) did an amazing job installing his rear-facing convertible seat in our car. When he was 16 months old she talked me out of turning him forward-facing, and at 3.5 years we're just deciding to turn him around now.

Monday's Mistake - can you spot the mistake/s in the picture?

To continue on our booster theme from last week, I thought I'd show two more common mistakes seen with booster seats.  Many parents think that because boosters are so easy to use (no installation required) that there couldn't possibly be a way to use them wrong.  Unfortunately, many booster seats are used improperly (like the ones below).

This picture shows two girls riding in high-back belt-positioning boosters.
The mistake on the girl in the front is much more obvious than the one for the girl in the back.
Can you identify both mistakes?
For bonus points, what type of injury pattern might you see in the girl in the front - how about for the girl in the back?
Post your answers below - and I will post the correct answer on Tuesday.

(Note: The child in the front is not riding in the front seat - this is a vehicle with 3 rows of seats)

Please note: These photos were not staged.  These photos were taken by real parents just like you who didn't know that they were using the boosters improperly.  9 out of 10 car seats are used incorrectly - don't let your child ride at risk.   If you are in the NYC or Baltimore areas, email us at info@thecarseatlady.com to schedule a private car seat installation lesson - otherwise, visit www.seatcheck.org to find someone in your area to teach you how to install your seats properly.

Thursday's Travel Tip: Flying (Safely) with Kids - Part 1

 

Poster Text: 

You make sure your carry-on bag fits overhead.  You tuck your purse under the seat in front of you.  You secure your seat back and tray table in their upright positions.  Doesn't your child deserve the same protection?  If there's turbulence during a flight, a child safety seat is the safest, most secure place for your little one.

Top 10 Reasons 

 

Why Your Child Should Ride in a Car Seat on an Airplane

1. They are safer! You can't hold your coffee cup during take-off & landing - doesn't your child deserve the same protection?  Children in a car seat are securely fastened to the airplane seat – just like everyone and everything else in the airplane cabin.
2. A child riding on your lap can easily fly out of your arms in rough turbulence and hit their head on the overhead bins.  
3. Most kids can't climb out of their car seats - but they can quickly figure out how to open the airplane seat belt and become unrestrained. 
4. Children are more comfortable in the car seat since it is familiar and just their size
5. Kids tend to sleep better in the car seat since it is more comfortable for them than the big airplane seat. 
6. You don't have to hold a squirmy infant or toddler on your lap for hours.  
7. It’s easier for parents to get up to stretch or use the restroom.
8. You will usually need your car seat to get to the airport safely and then also when you arrive at your destination.  Kids who don't ride in a car seat on the airplane, often don't ride in a car seat on the ride to or from the airport - which is exceptionally dangerous (and usually illegal too). 
9. The car seat stays in your possession throughout the entire trip so you do not have to worry about the car seat being lost or damaged by the airline.
10. Some crashes are survivable - this 3 year old was the only survivor of a horrible plane crash - rescuers found her hanging upside down in her car seat in the rubble of the aircraft with only minor injuries.  

Tuesday's Tech Tip: Why do some vehicle manuals warn that nothing should press against the back of the front passenger seat or be placed under that seat?

Here's the Short Answer
The warning applies to pressure against or objects under the FRONT PASSENGER seat (not the driver seat).  Advanced Air Bags (AAB), which are now standard equipment in all vehicles, use sensors to decide when to deploy.  Pressure against the seatback of the front passenger seat - such as from a rear-facing car seat or the feet of a forward-facing child - may cause a false reading by the sensors.  In a crash, the sensors might inappropriately react to this pressure and either inflate the airbag when it should have stayed deflated, or vice versa.  Even pressure under the seat - such as from objects placed under the front passenger seat - may affect the sensors.

Tips to Take Away - What Should You Do:

• As a rule, it is best to make sure that the rear-facing car seat does not press against the front passenger seat (one vehicle manufacturer explained that you should be able to slip a sheet of paper in between the rear-facing car seat and the front seatback)
• If a forward-facing child sits on the passenger side in the back seat, try to make sure they do not push their feet against the seatback of the front passenger seat
• Do not put anything underneath the front seat (including medical equipment)

Now that I piqued your interest, please read the long answer in this fantastic article from our friends at Safe Ride News.

If you are a CPS Tech, subscribe to the Safe Ride News Newsletter - it's a great way to stay up-to-date.

Answers to "Mistake Monday" 3/1/10

Please note:
Every seat is different - always read the manual to YOUR child's car seat as what applies to one seat may not apply to another.  The booster shown in these two pictures was the Graco TurboBooster backless.

Girl:

1. The arm rests are designed to keep the lap belt from riding up into the abdomen.  The lap belt is not placed in front of the arm rest, but rather behind the arm rest.  (See cartoon from Graco's manual showing proper routing of the lap belt)
2. The small screw that holds in the arm rest (into its higher or lower position) is not being used.
3. Yes, there are projectiles (laundry anyone?) 

Boy:

1. On this booster (as with most others), the shoulder belt should go under the arm rest that is closest to the seat belt buckle.  In the picture, his shoulder belt is over the arm rest closest to the buckle - just like in the misuse cartoon in Graco's manual.
2. The vehicle's seat back or head rest should come up to at least the top of his ears to reduce his chance for whiplash injuries.  

 

Note: Some people have mentioned that the boy seems quite old for a booster.  There is no maximum age for this booster.  Without doing the 5-step-test, it is impossible to say if he is ready to ride safely without a booster.  He might, however, benefit from a booster that is wider and deeper (so that the booster ends closer to where his knees bend).  The Sunshine Kids Monterey, Chicco Key Fit Strada, Britax Frontier 85, and Maxi Cosi Rodi XR are all great boosters for older, taller kids.

Teaching Tips - How to Know that a Person has Adequate Head Protection (against whiplash): 

The top of the ears is the same height as the base of the skull.  Therefore, if the head is supported at least this high, there is less chance for whiplash injuries.    

• For kids in a forward-facing car seat (with a 5-point harness)
• The top of the child's ears should be at or below the top of the plastic shell of the car seat
• For kids in a backless booster seat: 
• The top of the child's ears should be at or below the top of the vehicle seatback/head rest
• For kids in a high-back booster: 
• If the top of the child's ears are above the top of the vehicle seatback/head rest, you need to make sure that the booster is designed to provide adequate head protection for the child.  Many high-back boosters have relatively flimsy backs - and therefore require the support of the vehicle seatback/head rest to come up to at least the top of the child's ears.  Please read the manual for your booster to know if this applies.
• For adults: 
• When adjustable head rests are available, they should be positioned so that they come up at least as high as the top of the ears. 

Monday's Mistake - can you spot the mistake/s in the picture?

These pictures show two kids riding in their Graco Turbo Booster.
Can you identify the TWO mistakes in the girl's picture and the TWO mistakes in the boy's picture?
Post your answers below - can you spot all three mistakes?

I will post the answers on Tuesday.

Please note: These photos were not staged.  These photos were originally posted by real parents just like you who didn't know that they were using the booster improperly.  9 out of 10 car seats are used incorrectly - don't let your child ride at risk.   If you are in the NYC or Baltimore areas, email us at info@thecarseatlady.com to schedule a private car seat installation lesson - otherwise, visit www.seatcheck.org to find someone in your area to teach you how to install your seats properly.