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:

Infant Safety Seat Misuse and Risk of Injury

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.


(1). Pollack-Nelson C., Fall and suffocation injuries associated with
in-home use of car seats and baby carriers. Pediatr Emerg Care. 2000;

(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

Competing interests: No competing interests

12 December 2006
Ediriweera Desapriya
Research Associate
Ian Pike, Sayed Subzwari
Department of Pediatrics, Centre for Community Child Health Research 4480 Oak Street V6H 3V4