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:

Making Infant Car Safety Seats Safe --- a Low Tech Option

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
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
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


[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,
Tondon in printed clinical research edition.

[2] Tonkin SL, McIntosh CG, Hadden W, Dakin C, Rowley S, Gunn AJ.
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
for Prehospital Professionals: PEPP Resource Manual. Sudbury: Jones &
Bartlett; 2001.

[4] Dollberg S, Yacov G, Mimouni F, Ashbel G. Effect of Head Support
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.
1999;104:986 -- 987.

Competing interests:
None declared

Competing interests: No competing interests

16 December 2006
Tim Vemmer, MD FRCA DMCC
Specialist Registrar
Dept. of Anaesthesia, St George's Hospital, Blackshaw Road, London SW17 0QT