An Update on Newborns in Car Safety
Seats and the Infant Car Seat
Challenge Test
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Today’s 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
Child Passenger Safety
What we know, what we use, and what we do has
changed dramatically!
We’ve Come A Long Way –
for Baby!
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
Car Bed Options for Infants
Who Must Lie Flat
Dream Ride SE
Angel Ride
5 – 20 lbs
Birth – 9 lbs
19 – 26”
<21.5”
Hope
4.5 – 35 lbs
13 – 29”
Infant Car Seat Challenges:
Who, What, When, Where, Why and How?
Natalie Davis, MD, MMSc
Assistant Professor of Pediatrics
University of Maryland School of Medicine
Division of Neonatology
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
Why? Who?
Why do this test? (History of the ICSC)
Who should be tested?
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 <37 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
Local Statistics
• Premature: born <37 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/File:Maryland_in_United_States.svg
Who?
• All babies born <37 weeks gestational age (GA)
– Overall failure rate of 4.3%
• 2.4% in infants born early preterm <34 weeks GA
• 5.6% in late preterm born 34+0/7 – 36+6/7 weeks GA
• Who else?
–
–
–
–
Full term babies born <2.5kg
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
ICSC: What’s 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 <2.5kg? 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?
What?
What failure guidelines should be used?
Results
• Following AAP Guidelines
– 11% did not perform ICSCs
– 17% did not test all infants born <37 weeks GA
– 45% tested for <90 minutes
• Additional Criteria
– 45% included “Low Birth Weight” as a testing
criterion, testing all babies born <2.5kg
– No consensus on failure criteria for bradycardia or
desaturations
Davis NL, et al. Academic Pediatrics. 2013
ICSC Desaturation Failure Criteria
40%
35%
30%
Percent of NICUs
>60sec
>30sec
25%
>20sec
20%
>10sec
>5sec
15%
Any
10%
5%
0%
"Desat" <80%
<85%
<86%
<87%
<88%
<89%
<90%
<91%
<92%
<93%
Failure Saturation
Davis NL, et al. Academic Pediatrics. 2013
ICSC Desaturation Failure Criteria
40%
35%
30%
Percent of NICUs
>60sec
>30sec
25%
>20sec
20%
>10sec
>5sec
15%
Any
10%
5%
0%
"Desat" <80%
<85%
<86%
<87%
<88%
<89%
<90%
<91%
<92%
<93%
Failure Saturation
Davis NL, et al. Academic Pediatrics. 2013
ICSC Desaturation Failure Criteria
40%
35%
30%
Percent of NICUs
>60sec
>30sec
25%
>20sec
20%
>10sec
>5sec
15%
Any
10%
5%
0%
"Desat" <80%
<85%
<86%
<87%
<88%
<89%
<90%
<91%
<92%
<93%
Failure Saturation
Davis NL, et al. Academic Pediatrics. 2013
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
Suggested Failure Criteria
•
•
•
•
Apnea >20 seconds
Heart Rate <80 beats per minute for >10 seconds
Saturation <90% for >10 seconds
Respiratory distress not improved with proper
positioning
• Canadian Paediatric Society:
– Two episodes <88% for >10 seconds
When?
What to do when a baby fails?
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
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
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/files/car_bed.jpg
Safety: Car Seat vs. Car Bed
150 VLBW babies born <37 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
Failed ICSC…what 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
ICSC
Pass
Fail
Discharge in approved
car safety seat
Wait > 12-24 hours
and repeat ICSC
2nd Fail
Pass
Discharge in approved
car safety seat
Test in a Car Bed
Pass
Discharge in Car Bed
Return for retesting in
car seat at term or 2-4
weeks of age
Fail
Recommend further
evaluation and
admission for medical
work up
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 infant’s own semi-reclined
car safety seat
– At term equivalent (40 weeks) or 2-4 weeks after
discharge
– Repeat via pediatrician’s office or at pediatric
pulmonologists office
• Test in outpatient clinic
• Test as inpatient with polysomnography
Where?
Where is future research focusing?
Future Research
• Incidence and risk factors for failure of the
ICSC in full term, low birth weight (<2.5kg)
babies
• Recorded oximetry prior to the ICSC to predict
failure
• Inserts to improve oxygenation in the car seat
• ICSC in all infants?
How?
How should we counsel families?
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
Best Practice for ICSC
• Test can be done any time of night or day, but
make sure parents are aware
– Perform >24 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 family’s actual car seat
Suggested Failure Criteria
•
•
•
•
Apnea >20 seconds
Heart Rate <80 beats per minute for >10 seconds
Saturation <90% for >10 seconds
Respiratory distress not improved with proper
positioning
• Canadian Paediatric Society:
– Two episodes <88% for >10 seconds
Failed ICSC
• Assess for fit of infant in car seat, appropriateness of
positioning
• Update family
• Perform repeat ICSC > 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
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
THANK YOU!
-Natalie Davis
ndavis@peds.umaryland.edu
Anticipatory Guidance for
Expectant/New Parents
CPS Technicians:
• Review minimum weight for
their RF seat
• Discuss alternative seat options
Health Care Practitioners
Advise patients with high-risk or
multiple pregnancies to:
• Purchase RF car seat(s) early
if needed
• Look for RF car seat(s) with
• Ask questions:
• Singleton vs Multiples?
• When is due date?
• Estimates of baby’s size?
• Any concerns?
minimum weight of 4 lbs
• Discuss importance of small
harness dimensions
• Refer to CPS Techs/Resources
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 agency’s CPS policies and procedures
Youth/‘pre-driver’ curriculum and train-the-trainer sessions
One of our
free posters…
(11” x 30”)
Our 2009 training DVD
for healthcare providers
MD KISS Services
 Presentations/Trainings
 Car Seat Check-Up Events
 Skype Virtual Inspections/Assistance
 Car Seat Assistance Programs
 Information & Referrals
Kids In Safety Seats
Contact Info:
 Helpline: 800-370-SEAT (7328)
 Email: dhmh.kiss@maryland.gov
 Web: www.mdkiss.org
 Skype: mdkiss2
Thank you for participating today!
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