The Journal of Pediatrics
Volume 150, Issue 3 , Pages 215-216, March 2007

The Challenge of Car Safety Seats

  • James M. Greenberg, MD

      Affiliations

    • Corresponding Author InformationReprint requests: James M. Greenberg, MD, Division of Neonatology, Cincinnati Children’s Hospital Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229.

Division of Neonatology, Cincinnati Children’s Hospital Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio

Article Outline

 

In newborn intensive care units and special care nurseries throughout the United States, the discharge process typically includes a ritual known as the car seat challenge. The preterm infant, now of sufficient health and size to safely venture home, is first placed in a car seat, connected to a vital signs monitor and pulse oximeter, and then observed for an extended period of time. If specified parameters are achieved, the infant is deemed ready to safely travel in a car seat without the risk of untoward cardiopulmonary compromise.

See related article, p 224

Given the “objective” data obtained from a car seat challenge (number of apneic episodes, oxygen saturation values, and so on) one might suppose that the test is based on carefully considered scientific evidence. However, reviews of published literature speak to a different story.1, 2

The car seat challenge appears to originate from the practice of apnea monitoring and related testing popularized in the 1980s to determine readiness for discharge from the neonatal intensive care unit. No published evidence demonstrates that normal studies predict safe discharge. Similarly, little if any objective evidence supports the use of a car seat challenge to confirm safe infant automobile travel. The lack of evidence has not inhibited clinicians. Most nurseries discharging preterm infants use car seat challenge protocols, perhaps under the assumption that they represent a standard of quality care for newborn infants.

Protocols for car seat challenges are poorly standardized; an informal survey conducted during the preparation of this editorial identified observation times ranging from 30 minutes to 5 hours, along with a dizzying array of criteria for passing or failure. And what if the infant fails? Some re-test until the infant passes. Occasionally, a discharge is delayed for a day or two until the infant is rechecked and passes. Others simply discharge in a car bed under the assumption that it is safer. But once again, no objective studies have evaluated this question.

In this issue of The Journal, Salhab et al3 present a well-designed study to test the hypothesis that car beds present a safe alternative for infants failing their car seat challenge. Their work is important because they test the validity of an assumption in clinical practice, namely that infants who have apneic events in car seats, will not experience such problems when placed in a car bed. Their findings, that infants experiencing apneic events in car seats will also have these events with the same frequency in car beds, convey an important lesson for those of us who hope to practice evidence-based medicine. A recent report by Kinane et al4 reached a similar conclusion.

Often we pursue clinical practices that are not based on evidence, but rather clinical intuition. Sometimes our intuition is based on logical inference from laboratory-based investigation. Sometimes, the origin of our practices is murky. This should not make us feel bad; there is much in medical practice based upon experience, logical inference, and the like. However, we must resist the temptation to indefinitely embrace practices without appropriate study. In 2006, Vain et al5 published results of their large, well-designed, prospective, randomized controlled study of suctioning on the perineum for infants born through meconium-stained amniotic fluid. Their study tested the hypothesis that suctioning would not affect the incidence of meconium aspiration syndrome and found that this was indeed the case. Like car seat challenges and car beds, suctioning was an established practice thought to be useful but never carefully studied.

Neonatology would benefit from more studies like those led by Salhab, Kinane, and Vain. These investigators are to be commended for their willingness to resist the siren song of established practice to ask important clinical questions. Our zeal to do the right thing for our patients is always best focused through the lens of careful inquiry.

So what do we do about car seat challenges? Clearly many questions remain. Automobile travel is a fact of modern life. Yet newborn infants, particularly those born prematurely, are probably not designed to ride in cars for extended periods.3, 6 How long is safe and what restraint devices might be best are important areas for investigation. In the meantime, we might consider changing the notion of a car seat challenge to a car seat orientation. The American Academy of Pediatrics7 recommends that we evaluate cardiorespiratory stability through a “period of observation in a car safety seat” at discharge. Educating parents about proper positioning to support airway patency is certainly useful. We can also advise them to limit the duration of automobile travel with these vulnerable offspring, as well as the importance of close observation. Long trips should be discouraged, or if unavoidable, interrupted with frequent rest stops. Beyond these recommendations, we should resist the temptation to give parents the impression that passing a car seat challenge guarantees a free ride!

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References 

  1. Stein N. Car-seat test. [letter] Pediatrics. 2004;113:1469
  2. Pilley E, McGuire W. The car seat: a challenge too far for preterm infants?. Arch Dis Child Fetal Neonatal Ed. 2005;90:F452–F455
  3. Salhab WA, Khattak A, Tyson JE, Crandell S, Sumner J, Goodman B, et al. Car seat or car bed for very low birth weight infants at discharge home. J Pediatr. 2007;150:224–228
  4. Kinane TB, Murphy J, Bass JL, Corwin MJ. Comparison of respiratory physiologic features when infants are placed in car safety seats or car beds. Pediatrics. 2006;118:522–527
  5. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004;364(9434):597–602
  6. Merchant JR, Worwa C, Porter S, Coleman JM, deRegnier R-AO. Respiratory instability of term and near-term healthy newborn infants in car safety seats. Pediatrics. 2001;108:647–652
  7. American Academy of PediatricsCommittee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge. Pediatrics. 1999;104:986–987

PII: S0022-3476(06)01202-9

doi:10.1016/j.jpeds.2006.12.040

Refers to article:

  • Car Seat or Car Bed for Very Low Birth Weight Infants at Discharge Home

    Walid A. Salhab, Asif Khattak, Jon E. Tyson, Sharon Crandell, Jan Sumner, Beverly Goodman, Linda Fisher, Karen Robinson
    The Journal of Pediatrics March 2007 (Vol. 150, Issue 3, Pages 224-228)

The Journal of Pediatrics
Volume 150, Issue 3 , Pages 215-216, March 2007

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