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Car Safety Seats , Apparently Life Threatening, Practically Life Saving?
- Turab A SYED (9 December 2006)
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Infant Safety Seat Misuse and Risk of Injury
- Ediriweera Desapriya, Ian Pike, Sayed Subzwari (12 December 2006)
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Re: Car Safety Seats , Apparently Life Threatening, Practically Life Saving?
- Shirley L. Tonkin, Alistair J. Gunn (13 December 2006)
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Making Infant Car Safety Seats Safe --- a Low Tech Option
- Tim Vemmer, MD FRCA DMCC (16 December 2006)
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Turab A SYED, SpR (Specialist Registrar) LAT Trauma & Orthopaedics Northampton General Hospital NHS Trust, Cliftonville, Northampton,NN1 5BD, England, United Kingdom
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Dear Editor I read with great interest the article by TONKIN et al (1) from New Zealand in BMJ. They have provided interesting information. Although it was widely known that the pre-term infants (less than 37 week gestation) or who require intensive care admission at birth should preferably avoid travel in car safety seats for first month (2)and may suffer from desaturation, this is perhaps the first case series showing actual evidence of leading to apnea in normal term infants in a car safety seat (Which was not seen in study by Merchant et al (2)). This is obviously a matter of concern for parents and doctors alike. I myself being a parent of a 4 Month old baby and working in Trauma & Orthopaedics have special interest in safety of car seats ( in case of accident in specific & the safety for their occupant in general ) especially those seats which are rear-facing and semi-reclined. I would like to raise following points which need clarification It would be beneficial to know if the smoking status of father or other family members was noted? Was there any correlation between the age of presentation and the smoking status of other family members i.e. the children of smoking family presented at a younger age or towards the lower spectrum! Were these the first child of every family or were there multiple gestations? Authors have mentioned that the scene was recreated and 'position kept for long enough for care giver to recognize signs for concern'. This appears to be a brave undertaking! I would like to know whether parents had any reservation for this reconstruction to be carried out, especially taking into account the clinical risk management issue for any serious harm occurring. Was it easy to get an ethical committee approval for this maneouver? Authors have mentioned that infants were very young, when head control was not well developed. This may not be the case for the 6 Months old baby referred to in the age range of cases. Authors suggested that the parents were given advice including NOT leaving infants for excessive periods in car seat. I would like to know what this excessive time period is; 30 minutes or two Hours? Does that mean that if babies are sleeping and one is traveling one should get them out after this time period on a regular basis? I am also surprised that the reference quoted for this is AAOP 2005 publication in Pediatrics (3). I believe when this study was carried out in 1999-2000 this advice would not have been available!! Authors have mentioned 'Prominent Occiput' as a probable cause. I think I may have overlooked this in the article as I was unable to find any reference to the occiput size of this cohort or any cranial measurements. It is vital to know whether the cohort under consideration was Caucasian or a mix population group including Polynesian, Afro-Carribean. This is important as the Occiput shape and size would be different for these groups. Is it possible that 'Prominent Occiput' may be the only common factor among this cohort? Has this been excluded? If it is the only group then as a profession we can offer targeted advice rather than alarming all the parents!! Authors state that the permission to publish was obtained from only seven patients but they refer to the mean ages of the nine patients! As a profession it is our duty to ensure that this important information must be taken in context and avoid its exploitation by media for their quest for sensational news. One must remember that each year car seats save thousands of precious lives. Finally this article illustrates that the findings of this interesting case series took about 06 years to be able to be disseminated across the medical profession , unless authors did not prepare it, which is highly unlikely considering the significance of this information! References: 1. Shirley L Tonkin, Sally A Vogel, Laura Bennet, , Alistair Jan Gunn, Apparently life threatening events in infant car safety seats BMJ 2006;333:1205-1206 (9 December), doi:10.1136/bmj.39021.657083.47 2. Merchant JR, Worwa C, Porter S, Coleman JM, deRegnier RA. Respiratory instability of term and near-term healthy newborn infants in car safety seats. Pediatrics 2001;108:647-52 3. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005;116:1245-55. Competing interests: None declared |
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Ediriweera Desapriya, Research Associate Department of Pediatrics, Centre for Community Child Health Research 4480 Oak Street V6H 3V4, Ian Pike, Sayed Subzwari
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We read recent BMJ article and we certainly agree that infant safety seats (ISS) are designed with the goal to reduce the number of infant passengers killed or injured in motor vehicle crashes. When used for their intended purpose, ISS’ hold great potential to decrease the risk of infant death or injury. It is of concern that ISS misuse may be occurring among caregivers using ISS’ outside motor vehicles thereby putting their infant at risk of injury. The objective of the current study was to describe incidence and factors associated with injuries from ISS misuse among infants aged 0 – 1 years presenting to the British Columbia (BC) Children’s Hospital Emergency Department over 6 years (1997 – 2002). The results of our recent study in BC children hospital support previous literature suggesting that ISS misuse may expose infants to falls and superficial head injuries (1, 2). Superficial head injuries from ISS misuse are of particular concern because infant skulls are malleable and susceptible to fracture and intracranial injury (3). Narratives accompanying the injury data indicated that 3 patterns of injury associated with ISS misuse are injuries resulting from falls from: 1) placement of the ISS on an elevated surface; 2) falling out of the ISS while being carried and 3) ISS overturn on hard floors. Due to the patterns demonstrated in falls related injuries, it is possible that caregivers are not anticipating how readily or how quickly the ISS would roll or tip over when placed on an elevated surface. ISS manufacturers should be advised to expand their instructions to include advice on ISS misuse. ISS manuals would benefit by having the following messages: 1) never place ISS on an elevated surface and 2) always use the ISS harness in all settings and 3) do not use a ISS outside of the motor vehicle setting. Warnings in word form should be augmented with pictorial representations that articulate the main messages (2). Pictorial diagrams improve the usability and appear to improve label compliance, especially when a label is positioned in an appropriate location (4). In addition to changes to instruction manuals and labels, a previous study suggested there is a need for innovation in the design of ISS, so that they are more functional and stable (2). To increase stability, ISS design features could be improved to reduce the risk to children, and to allow for multi-purpose use both inside and outside a motor vehicle. Frequently parents lack the knowledge of effective safety measures to prevent injuries to children, and consequently misuse protective safety devices (5). Caregivers could benefit from education on proper ISS use by messages placed in a variety of accessible settings. Potential settings include primary care offices, community-based organizations, child care settings, emergency departments, maternity wards and commercial outlets and point of sale locations. Primary care could increase their involvement in education efforts as per the American Academy of Pediatrics who recognize injury prevention education for caregivers should be priority area for counseling during routine health maintenance visits for young children (6). A recent review by Gittelman and Durbin (2005) (7) has suggested that an emergency department visit for an injury represents a "teachable moment" for the patient and their family, which may make the injured more receptive to educational information. REFERENCES (1). Pollack-Nelson C., Fall and suffocation injuries associated with in-home use of car seats and baby carriers. Pediatr Emerg Care. 2000; 16(2):77-9. (2). Wickham T, Abrahamson E., Head injuries in infants: the risks of bouncy chairs and car seats. Arch Dis Child.2002; 86(3):168-9. (3). Lallier, M., Bouchard, S., St-Vil, D., Dupont, J., Tucci, M., Falls from heights among children: A retrospective review. Journal of Pediatric Surgery 1993; 34 (7) 1060-1063 (4). Rudin-Brown C.M., Greenley M.P., Barone A., Armstrong J., Salway A.F., Norris B.J., The design of child restraint system (CRS) labels and warnings affects overall CRS usability. Traffic Inj Prev. 2004; 5(1):8-17. (5). Duhaime A.C., Alario A. J., Lewander W.J., Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992; 90:179 –185 (6). Eichelberger M.R., Gotschall C.S., Feely H.B., Harstad P., Bowman L.M., Parental attitudes and knowledge of child safety. Am J Dis Child. 1990; 144:714 –720 (7). Gittelman, M.A., Durbin, D., Injury prevention: Is pediatric Emergency Department the appropriate place? Pediatric Emergency Care 2005; 27 (7) 460-467 Competing interests: None declared |
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Shirley L. Tonkin, General Practitioner New Zealand Cot Death Association, Eden Terrace, Auckland, New Zealand, Alistair J. Gunn
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We appreciate the comments by Dr Syed, and would like to clarify several points. We do not know the smoking status of other family members in this series. Nicotine is known to delay or attenuate responses to hypoxia – but of course this does not explain the underlying reasons why the infants needed to arouse in the first place. Some of the babies in our series were first born, but others had varying positions in the families. Our sample was too small to relate any response to birth order. Re scene recreation. This was carried out by the care giver in response to a request to ‘show me how baby was when you found him/her and were worried‘. The evaluation was part of a routine medical service provided for medical referrals for surveillance with apnoea alarms for apparent life threatening events. Infants were fully monitored and were not at risk. The caregivers fully understood beforehand the goal of understanding what had happened, and all said afterwards that they felt much better now that they understood that for their baby the problem was the specific situation, and thus could avoid it happening again. As we state in the article, precautionary apnoea monitoring was also provided for all infants and no further events occurred. Re the age of the babies suffering the ALTE’s. Note that the one 6 months old baby was born prematurely, whereas all of the full term babies were very young. Thus the developmental range is not as wide as it first appears. We believe that it is highly unlikely that there is any real ‘safe’ period for leaving babies asleep in a position of head flexion onto the chest in car safety seats, especially when those seats are placed on the floor out of the car when they are often more upright, promoting greater ‘head flop’ forwards. Even in cars we recommend infant observation by the care giver – a mirror can be rigged to watch an infant in the back seat. Thus, our general advice at present to parents is that baby should be taken out of the seat immediately when not in the car, and placed to sleep flat, in a normal cradle or bassinet. Re infant occiput. We have previously reviewed the relevant anatomy (Tonkin 2002). For all newborn infants of all ethnic groups the spine is straight and the head is large (between 1/3 and ¼ of the total length) The neck is very short. The head sits on the spine like a toffee apple on a stick with about ¼ of the head depth being behind the spinal line. There are individual differences in the occipital protuberance but it is always present in some degree. In many small babies when this occipital bulge is forced to be in line with the spine, the head flexes forwards –the chin is pressed onto the chest, and that in turn pushes the loosely articulated jaw backwards carrying the tongue inside it posteriorly to obstruct the upper airway. We have confirmed that this is an important effect in premature babies in car seats (Tonkin 2003) using simultaneously radiographs and polygraphs. In that setting we reported that this problem could be alleviated with the use of a foam plastic insert in the seat to allow the head to remain upright in sleep. We very strongly agree that the correct use of car safety seats has saved infant lives and will continue to do so, but at the same time they may have some potential risk. The cases that we report here strongly suggest that this risk is mainly when they are used as a household bed, for which they were not designed or intended, instead of for their intended purpose. References ; Tonkin SL, Gunn TR, Bennet L, Vogel SA, Gunn AJ. A review of the anatomy of the upper airway in early infancy and its possible relevance to SIDS. Early Hum Dev. 2002;66:107-121 Tonkin SL, McIntosh CG, Hadden W, Dakin C, Rowley S, Gunn AJ. Simple car seat insert to prevent upper airway narrowing in preterm infants : a pilot study Pediatrics 2003; 112: 907-13 Competing interests: None declared |
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Tim Vemmer, MD FRCA DMCC, Specialist Registrar Dept. of Anaesthesia, St George's Hospital, Blackshaw Road, London SW17 0QT
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Editor, Tonkin et al. describe the cases of nine infants having apparently life threatening episodes while restrained in car safety seats [1]. The cause of these events seems to be related to the design of the car safety seats: The seats do not provide space for the infant's large occiput, leading to forward flexion of the neck and airway obstruction. A car seat insert increasing the gap for the occiput has been designed by the same group three years ago [2] but is not commercially available in the United Kingdom. A far easier `low-tech' solution is to put a folded towel behind the baby's shoulders. This simple method is commonly used in paediatric anaesthesia and in prehospi- tal emergency care to keep the airway open and to avoid neck flexion in infants immobilised on a spine board [3]. This is not stating the obvious: A group from Tel Aviv went to great length to prevent lateral head movement in infant car seats and unsurprisingly found no difference in the frequency of hypoxia [4]. A folded towel or similar padding will not change the restraining function of the seat in an accident, certainly not more than a winter jacket without hood. Towels are readily available to all parents, all we need to do is to show them how to do it. A demonstration of a few minutes could save a baby from airway obstruction and can be integrated easily in the `car seat test' [5]. Midwives, health visitors, and general practitioners may be in the best position to teach parents how to use an infant car safety seat safely. References [1] Tonkin SL, Vogel SA, Bennett L, Gunn AJ. Apparently life threatening events in infant car safety seats. Br Med J. 2006 9th December;333(7580):1205 -- 1206. First author given as Tonkin in bmj.com, Tondon in printed clinical research edition. [2] Tonkin SL, McIntosh CG, Hadden W, Dakin C, Rowley S, Gunn AJ. Simple Car Seat Insert to Prevent Upper Airway Narrowing in Preterm Infants: A Pilot Study. Pediatrics. 2003;112(4):907 -- 913. [3] Gausche-Hill M, Brownstein D, Diekmann RA, editors. Pediatric Education for Prehospital Professionals: PEPP Resource Manual. Sudbury: Jones & Bartlett; 2001. [4] Dollberg S, Yacov G, Mimouni F, Ashbel G. Effect of Head Support on Oxygen Saturation in Preterm Infants Restrained in a Car Seat. Amer J Perinatol. 2002;19:115 -- 118. [5] American Academy of Pediatrics, Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge. Pediatrics. 1999;104:986 -- 987. Competing interests: None declared |
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