Intended for healthcare professionals

Rapid response to:


Apparently life threatening events in infant car safety seats

BMJ 2006; 333 doi: (Published 07 December 2006) Cite this as: BMJ 2006;333:1205

Rapid Response:

Car Safety Seats , Apparently Life Threatening, Practically Life Saving?

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

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

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

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

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!


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

Competing interests: No competing interests

09 December 2006
Turab A SYED
SpR (Specialist Registrar) LAT Trauma & Orthopaedics
Northampton General Hospital NHS Trust, Cliftonville, Northampton,NN1 5BD, England, United Kingdom