The Healthcare Provider’s
Role in
Child Passenger Safety
PA Chapter
American Academy of Pediatrics
Traffic Injury Prevention Project
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Goals of Program
Explain
the Pennsylvania laws
concerning child passenger safety.
Describe
“best practice”
concerning child safety seats.
List
key educational messages regarding
proper use of child restraints.
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Child Passenger Safety Law
All drivers are responsible for securing children in the appropriate child
restraint system.

All children from birth up to age 4 must be secured in an approved
child safety seat anywhere in the vehicle. Violators of this primary law
are subject to a fine of $75.00 plus Court Costs, EMS, MCARE, and
Administrative Fees. Total cost $161.00

All children age 4 up to age 8 must be secured in a seat belt system
and appropriate child booster seat anywhere in the vehicle. Violators
of this primary law are subject to a fine of $75.00 plus Court Costs
EMS, MCARE and Administrative Fees. Total cost $161.00

All children age 8 up to age 18 must be secured in a seat belt system
anywhere in the vehicle. Violators of this primary law are subject to a
$10 fine plus EMS, MCARE, and Administrative Fees. Total cost $60.00
According to the law (§ 4581. Restraint systems)—subsection Occupant Standards
A child passenger restraint system and a child booster seat shall be used as designated by the
manufacturer of the system in motor vehicles equipped with seat safety belts and shall meet
the Federal Motor Vehicle Safety Standard. Children between the ages of 8 and 18: Must be
properly restrained in a vehicle seat belt system.
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Hospitals Role in CPS
PA Vehicle Code Section 4583
(a) Availability of restraint devices – the hospital, in conjunction with
the attending physician, shall provide the parents of any newborn
child with any information regarding the availability of loaner or
rental programs for child restraint devices that may be available in
the community where the child is born.
(b) Instruction and education programs –The department shall provide
instructional and educational program materials through all current
public information channels and to all relevant State and Federally
funded, community based programs for maximum distribution of
information about this child passenger protection law.
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Why Are We Here?



Traffic crashes are still the leading
cause of unintentional deaths and
severe injuries in the United States.
Only diseases like cancer, heart disease,
and stroke kill more people than motor
vehicle crashes.
Every day in the United States, an average of
4 children age 14 and younger were killed and
490 were injured in motor vehicle crashes
during 2009.
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NHTSA Statistics / CRS Use
NHTSA 2009 Survey
 Restraint use for children age 1 to 3 years
increased from 92 % in 2008 to 96 % in 2009
 Restraint use for all children under age 13
remained unchanged at 89%
Note: Restraint use for all children from birth to 7 years old stood at 88 percent in 2009 as
compared to 87 percent in 2008 from the 2009 National Occupant Protection Use Survey
(NOPUS)

41 percent of 4 to 7 year-old children ride in
booster seats
 Virtually unchanged from the prior year.
.
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2010 PA Crash Facts CRS
As shown below (2006-2010 crashes
involving children under age four), the % of
deaths and injuries (within restraint type by
row) were lower when restraints were used.
From 2006-2010, 82% of the children under
age four who were involved in crashes and
restrained in a child seat sustained no injury.
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2009 PA Child Traffic Fatalities
Age 14 and under by Age Groups




<1 - 2
1 - 3 years - 3
4 - 7 years - 12
8 - 14 years -15
Total Child Traffic Fatalities 14 & under = 32
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Fatalities & Injuries
Fatalities are just the tip
of the iceberg:
For every 1 death there are:
45 injuries requiring
hospitalization
and
1100 other
injuries requiring
medical care.
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Three Collisions in a Crash
1st: Vehicle collision
2nd: Human collision
3rd: Internal collision
1st
2nd
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3rd
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Child Restraint Effectiveness
71% effective in reducing
deaths for infants.
 54% for 1 to 4 year olds.
 Reduces the need for
hospitalization by 69%.

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5 Ways Restraints Prevent Injury
1.
2.
3.
4.
5.
Prevents ejection.
Contacts the strongest parts of the
body.
Spread forces over a wide area of
the body.
Helps the body to “ride down” the
crash.
Protects the head and spinal cord.
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NEW AAP Guidelines for Car Seat Use




All infants and toddlers should ride in a rear facing car safety seat until they are 2
years of age or until they reach the highest weight or height allowed by their car seat's
manufacturer.
All children 2 years or older, or those who have outgrown the rear facing weight or
height limit for their car safety seat, should use a forward facing car safety seat with a
harness for as long as possible, up to the highest weight or height allowed by their car
safety seat's manufacturer.
All children whose weight or height is above the forward facing limit for their car
safety seat should use a belt positioning booster seat until the vehicle seat belt fits
properly, typically when they have reached 4 ft 9 inches in height and are between 8
& 12 years old.
When children are old enough and large enough to use the vehicle seat belt alone,
they should use a lap and shoulder belt. All children younger than 13 should be
restrained in the rear seat of the vehicle.
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AAP Policy
Released March, 2011
Algorithm
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NHTSA New Guidelines
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Selecting the Correct
Child Restraint
Correct selection is
based on the child’s:

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

Age
Weight
Height
Physical
Development
Behavioral Needs
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Rear Facing Position
“All infants and
toddlers should ride in
a Rear Facing Car Safety
Seat until they are 2
years of age or until
they reach the highest
weight or height
allowed by their car
safety seat’s
manufacturer.”
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Rear Facing Only (Infant Seat)



Rear facing ONLY.
Birth/4-5 pounds
to 20 – 22 (most
models) or 30/35
pounds.
When the head is
1” below top of
shell.
Chicco Key Fit 4-30lbs
with newborn/preemie insert
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Rear Facing Talking Points


Never place a rear facing car seat in front of an
active passenger side air bag (front seat).
Until age 2, children are at least 75% safer
rear-facing than forward-facing.
Article Injury Prevention 2007; 13: 398-402 Car Safety Seats for children: rear facing for best
protection

Children in the second year of life (12-24 mos.)
are over 5 times less likely to be seriously injured
or die in a crash if riding rear facing.
Article Injury Prevention 2007; 13: 398-402

Follow manufacturers instructions for using and
installing car seat at the appropriate angle.
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Rear Facing & Forward Facing
Crash Tests
Rear Facing video
Forward Facing video
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Development of the neck vertebrae
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Rear Facing Only
(Infant Seat)
 Supports entire head,
neck & back, reducing
stress to neck and spine
in a crash.
 May have a 5-point or Vharness.
 Some have a detachable
base.
Check instructions for angle and angel indicator
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Rear Facing Convertible



Rear facing until 20 to 30/45 lbs and a
minimum of one year old.
Use in a semi-reclined position.
Tray not appropriate for premature or small
infant.
Five Point Harness
Tray Shield
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Convertible Seats RF Longer
Nearly every convertible seat on the market has a 30/35lbs rear
facing max. weight limit. These are only three examples of
convertible seats that can be used rear-facing to 40 or 45lbs
Graco My Ride 65
Safety Surround
40lbs RF
Diono
Radian 100, 120 & RXT
40 & 45lbs RF models
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Safety First Complete Air
40lbs RF
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Securing Child
In Rear Facing Seats
Back & bottom flat into CRS.
 Rolled cloth at crotch strap,
if necessary.
 Rolled blankets at sides for
positioning.
 Harness at or below the
shoulders.
 Retainer clip at armpit level.

Always follow the manufacturer’s instructions.
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AAP Strengthens
Long Standing Advice


The AAP has strengthened its advice that
CRs and other sitting devices are not
recommended for routine sleep for infants
They have included the warning that infants
younger than 4 months are particularly at
risk in these seating environments because
they “might assume positions that can create
risk of suffocation or airway obstruction.”
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Pinch Test
Test at child’s shoulder
Try to pinch webbing
up and down
Your fingers should slide off
Harness straps are too loose
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Rear-Facing Back Angle
30°
45°
Level with
the Ground
 Back is primary restraint
 Balance with comfort and
keeping airway open
 Range - 30o to 45o according to
manufacturer’s
instructions
 Newborns more reclined
 More upright as child
grows
 Car bed option for special
needs
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Forward Facing Position
“All children 2 years or
older, or those younger
than 2 who have outgrown
the rear facing weight or
height limit of their car
safety seat should use a
Forward Facing Car Safety
Seat with a harness for as
long as possible, up to the
highest weight or height
allowed by their car safety
seat’s manufacturer.”
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Forward Facing Convertible
“Turn Around Time”




Can forward face (after
minimum of 1 year and 20 lbs.),
longer if seat allows up to 3035/45 lbs.
Starting at 18-24 months in age.
Most seats have harnesses that
go up to 40lbs. Some car seats
have harnesses up to 65 lbs.
Adjust
recline
angle to
upright
Seat in upright or semi-upright
position.
Always follow the manufacturer’s instructions.
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Forward Facing Convertible Seat
Harness:
 5-Point
(recommended)
 Tray Shield
Harness in the reinforced
slots at or above shoulders.
Generally, must use top slots
when forward facing.
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Forward Facing Only Seats




Forward facing for
children over 1 year
and 20 to 40-65 lbs.
Some HW models may
even go to 80 lbs. (Seat
shown)
Some can ONLY be used
with the harness.
Some have a removable
harness.
Britax Regent FF
min 1yr. 22lbs to 80lbs.
53” or less
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Forward Facing
Combination Seats
Combination child safety seat /
boosters:

Forward facing only.

Most have a 40 pound weight
limit for the internal harness.
Some car seats may
accommodate higher weights,
50-65lbs.

Must remove the harness and
use with lap and shoulder belt
for the BPB when reach max.
harness weight or height.
Combination Harness/BPB
Harness to 70lbs and a booster to
120lbs.
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Harness Rules: Forward
1. Slots: Convertible Seats: Top slot
or above the reinforcement bar.
Forward Facing Only Seats: First
level at or above the shoulders.
2. Harness Retainer Clip:
Armpit or Mid-chest level.
3. Tightness: SNUG
Should not be able to pinch any
slack in the harness.
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Four Elements to Achieve
a Correct Installation
1.
2.
Direction – Rear facing vs forward facing.
Location in the vehicle.
 Children are 37% less likely to die when
seated in a back seat.
 Seat selection is based on the needs of all
passengers.
3. Correct belt path – Follow the manufacturer’s
instructions.
4. Tight Installation.
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LATCH
Lower Anchors and
Tethers For Children
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LATCH Lower Anchor
Locations
in Vehicles
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TETHERS
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Why Use a Tether Strap?
(Credit: Lower Anchors and Tethers for Children – 2005, Safe Ride News Publications)



Tether strap can improve
performance of CR when
its use is recommended
by the manufacturer.
Reduces the forward
movement and rotation
of the seat
Adds additional stability
to CR installation
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Belt-Positioning Booster
“All children whose
weight or height is above
the forward-facing limit
for their car safety seat
should use a BeltPositioning Booster Seat
until the vehicle seat belt
fits properly, typically
when they have reached
4 feet 9 inches in height
and are between 8 and 12
years of age.”
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Booster Seats
Provide a transition from CR with
harness to a vehicle lap and
shoulder belt.
Minimum weight
ranges: 30-40 lbs.
Backless booster
Maximum weight
ranges: 60-120 lbs.
Max. height limits
vary
High back booster
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Why a Booster Seat?
1.
Protects children too
large for a CR with
harness but too small
for a simple seat belt.
2.
Increases crash
protection from
injuries
Incorrect belt
fit because
there is no
booster seat
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Correct belt fit with
belt-positioning
booster
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Basic Booster Seat Reminders

WARNING:
 Belt-positioning
booster seats can
only be used with
lap and shoulder
combination safety
belts.
 Belt-positioning
booster seats must
NEVER be used
with just a lap belt.
Courtesy Children’s Hospital of Philadelphia
Play Video
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Securing Children
In Booster Seats

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


Requires Lap & Shoulder belt.
BPB fits flat on vehicle seat
between safety belt anchors.
Lap belt positioned low
across top of thighs and
shoulder belt across chest.
Knees bend comfortably.
Child has appropriate
head restraint.
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Shoulder belt positioners
Seat Belt Syndrome
Spinal cord or soft tissue
damage due to:
-Improper placement of lap
belt over the abdomen.
-Lap belt that rides up onto
abdomen.
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Lap and Shoulder Belts
“When children are old
enough and large
enough to use the
vehicle seat belt alone,
they should always use
Lap and Shoulder Seat
Belts for optimal
protection.”
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Seat Belts
4. Shoulder belt
crosses center
collar bone and
center chest.
1. Sit all the
way back.
3. Lap belt fits low
on hips, touching
thighs.
2. Knees bend
comfortably at the
edge of the seat.
5. Must be able to stay for the entire trip.
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Proper Belt Fit Prevents…
Courtesy Children’s Hospital of Philadelphia
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CHILD PASSENGER SAFETY
FOR
SPECIAL NEEDS
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AAP Policy Statement Status
Safe Transportation of Newborns at Hospital Discharge
By AAP Committee on Injury, Violence, and Poison Prevention
Published in 1999
Reaffirmed in 2003, 2006
Safe Transportation of Premature and Low Birth Weight
Infants – now a Clinical Report
By AAP Committee on Injury, Violence, and Poison Prevention
and Committee on Fetus and Newborn
Published in 1996
Released May 2009
Selecting and Using the Most Appropriate Car Safety Seats
for Growing Children: Guidelines for Counseling Parents
By AAP Committee on Injury, Violence, and Poison Prevention
Published in 2002
Under revision – completion in 2010?
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CRS For Small Infants
Infant Seats that start at birth:
 Combi Shuttle: birth to 33lbs & 33” w/ base new model
 Combi Navette: birth to 22lbs seated height 18”or less (inst. sales)
 Orbit G2 Infant Car Seat: up to 22 lbs / 29”
Infant seats with a 3 to 4-pound minimum include:


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







Aprica A30 4-30lbs
Britax Chaperone: 4-30 lbs / 32”
Chicco Key Fit & Key Fit 30: 4-22 lbs / 30” 4-30 lbs 30”
Cybex Anton: 4-32 lbs / 30”
Safety First On Board 35 Air
Evenflo Embrace 35: 4-35 lbs
Evenflo Secure Ride 35 4-35lbs (in process changing to 4lbs.)
Graco new Snug Ride 35 4-35 lbs
mia Moda Certo: 4 to 22 lbs / 29”
Safety First Comfy Carry Elite 4-22lbs
Safety First On Board 35 Air 4-35 lbs. / 32”
Summer Prodigy Infant Seat 4-32 /32”
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CRS For Small Infants
Convertible seats that start at 3 or 4lbs:
Combi Coccoro: RF 3-33 lbs (FF 20-40lbs)
Dorel Maxi Cosi Pria 70 RF 4-40 lbs (FF22-70lbs)
Graco Classic Ride 50 4 - 40 lbs (FF 20-50lbs)
Graco My Ride 65 Safety Surround RF 4–40 (FF 20-65)
Coming Soon: Feb. 2012 Graco My Size 65 4-40lbs
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AAP Clinical Report
 Replaced the 1996 policy statement
Safe Transportation of Premature and Low
Birth Weight Infants
 Reviewed by AAP Board of Directors
 What’s new?
More evidence
More specific clinical guidance
Length of time 90 -120 min. or length of travel whichever is longer
Retest in car bed if failed tolerance test and car
bed is being considered
Follow up should be addressed
New section on research implications
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Summary AAP Clinical Report
 extend the “observation period” of the child in his/her child
restraint prior to discharge of low birth weight or premature
infants to 90-120 minutes, or the length of travel home,
whichever is the longest. The report also recommends that a
trained staff member perform this observation.
 provide interventions such as a car bed, supplemental oxygen,
continued hospitalization, and further medical assessment if the
child fails the observation period.
 provide additional observation periods after the child is
discharged and prior to moving the infant from a car bed to a
rear-facing infant restraint.
 limit the time preemies and low birth weight infants spend in
child restraints to essential travel.
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Special Conditions
High Risk Infants:
 Any infant<37 weeks gestation, low
birth weight or with any medical
condition that places the child at risk
for apnea, bradycardia or oxygen
desaturation.
 These infants must undergo a period
of observation to assure safety in the
semi-reclined CRS prior to discharge.
 This is necessary regardless of where
the baby is housed in the hospital
(NICU, NB nursery, Pediatric Floor).
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Special Conditions
Other “High Risk” medical conditions:




Children with developmental delays.
Children with neuromuscular conditions.
Children with chronic lung disease or oxygen
requirement.
Children with severe GERD
or other GI conditions.
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Review Tolerance Testing Procedures

Perform an observation period in the CRS to be used.

Position infant in seat properly for optimum restraint use





Maintain the proper recline angle approved for car seat use (no
more than 45o) during the monitoring.
May stabilize infant with lateral rolls on the side to maintain
position and a crotch roll to prevent submarining.
Monitoring should be done within 1- 7 days prior to discharge.
Monitoring should be done for a minimum of 90 to 120 minutes
or the expected travel time, whichever is longer.
Any infant who develops apnea, bradycardia or oxygen
desaturation, as defined by testing guidelines, during the
observation has failed the testing.
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Recommendations when failed testing:
 Consider further medical evaluation and intervention.
 Consider continued hospitalization until stable.
 Consider supplemental oxygen.
 Consider retesting in a car bed appropriate for the weight and size
of the infant.
 Parents should be counseled to avoid other upright positioning
devices including swings, infant seats and infant carriers.
 If the infant is discharged in a car bed, the physician should
consider scheduling a retest at a later time to assess the infant’s
readiness to graduate to standard child restraint and ride in the rearfacing semi-upright position.
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Car Seat/Car Bed Challenge Codes



The AAP has been successful in getting Current
Procedural Terminology (CPT) codes assigned to
car seat car bed challenge test. Effective 1-1-12
94780: Car seat/bed testing for airway integrity,
neonate, with continual nursing* observation and
continuous pulse oximetry, hear rate and
respiratory rate, with interpretation and report; 60
minutes
94781: Each additional full 30 minutes of the
procedure described in code 94780
AAP Clinical Report Recommends 90-120 minutes or the length
of the travel time home
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Angel Guard
Angel Ride Car Bed
 < 9 pounds
 < 20”
 Supine
 Right-side positioning or prone only if medically
necessary
 Premature or low birth weight infants
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Pediatrician’s Role in
Child Passenger Safety



First interaction:
prenatal visit
Second interaction:
hospital discharge
Third interaction:
first office check-up
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When You Only Have 5
Minutes in the Office
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What you can you do in the
office?
Children that have
outgrown or too small
for their seat
Non-regulated
products
Harness loose, twisted , retainer clip too low - not at armpit level
Focus on best practice and what you can see that is not correct.
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Healthcare Provider’s Role in
Child Passenger Safety
Parents Need To Know:
 Always read Manufacturer’s instructions
 Infant seats for newborns better fit
 Don’t use non-regulated products
 Second hand seats not recommended
 Life span of car seat / seat expirations
 Back seat is safest
 Enough safe seating for multiple children
 Some retail seats can be used for Special Needs
and some Medical Car Seats can be Prescribed.
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Child Passenger Safety Update
Review of what’s new:
 LATCH various designs
 Lap and shoulder belts in all
positions
 Harness Adjustment designs
 Ease of Use Ratings
 Higher weight seats -call PA
TIPP for updated list /AAP
Shopping Guide online
www.pakidstravelsafe.org
RF: 5lbs to 40lbs
FF: 20lbs to 65lbs
BPB: 40lbs to 100lbs
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New Features
 Anti rebound bar
 Side Impact Protection
 Lock Offs
 Car Seats that give you
feedback?
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NHTSA Ease-of-Use 5-Star Ratings: NHTSA uses a five-star
rating system to help consumers evaluate the four basic
category ratings:
= Excellent features on this child
restraint for this category.
= Above average features on this
child restraint for this category.
= Average features on this child
restraint for this category.
= Below average features on this
child restraint for this category.
= Poor features on this child
restraint for this category.
N/A
www.nhtsa.dot.gov
= Does not contain any features
that require a rating.
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





NHTSA website has info. sheets in
English and Spanish that you can use:
Trunk Entrapment
Power Windows
Vehicle Rollaway
Seat Belt Entanglement
Hyperthermia & Heatstroke
Backover
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Healthcare Provider’s Role in
Child Passenger Safety
Helpful hints:
 Keeping children
buckled
 Testing limits
 Suggestions
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Healthcare Provider’s Role in
Child Passenger Safety

Be a resource

Provide current materials

Certified CPS technician
on staff

Staff Trainings

Child safety seat clinics
www.pakidstravelsafe.org
1-800 CAR BELT
Resources

PA TIPP
PA Traffic Injury Prevention Project
1-800-CAR BELT
www.pakidstravelsafe.org

www.paaap.org

www.nhtsa.dot.gov
THANK YOU
www.pakidstravelsafe.org
1-800 CAR BELT
www.pakidstravelsafe.org
1-800 CAR BELT
PA Chapter
American Academy of Pediatrics
Traffic Injury Prevention Project
Rose Tree Corporate Center II
1400 N. Providence Road
Suite 3007
Media, PA 19063-2043
1-800-CAR-BELT
www.pakidstravelsafe.org
www.pakidstravelsafe.org
1-800 CAR BELT