The Infant Car Seat Challenge

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The Infant Car Seat Challenge

• Pam Homiak, MPH RN CPST-I
• MIEMSS
• Michelle Spencer, RN CPST-I
• Frederick Memorial Hospital

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The Infant Car Seat Challenge

• Hot topic right now in CPS and for hospitals
• The only available method of testing to see if a
  conventional car seat is appropriate for a
  high-risk newborn being discharged home from the
  hospital
• This test has been found to be reliable
• Intent is to prevent cardiorespiratory compromise
  in newborns as they are being transported home

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The Infant Car Seat Challenge Problems

• Lack of research
• Lack of standardization in implementation
• Lack of resources

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The Infant Car Seat Challenge What We Know

• Certain newborns are at risk for apnea when
  riding in a car seat
• Periods of no breathing can be potentially
  dangerous
• Goal prevent any risks to the newborns health
  try to ensure their safety while riding in the
  vehicle
• Who should be tested?
• Infants less than 37 weeks gestational age
• Infants with history of apnea, bradycardia,
  desaturations
• Infants with any medical conditions that put them
  at risk
• Lung disease requiring oxygen
• Neurologic diseases
• Additional airway problems
• A car seat must be appropriate for the maturity
  medical condition of the infant

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The Infant Car Seat Challenge Sources of
Information

• Where are we getting information on the car seat
  challenge?
• American Academy of Pediatricians (AAP)
• Clinical Report (2009)
• Not a set of rules for physicians, based on
  systematic review, standard of care, or a legal
  document
• Does not specify parameters for fail
• Riley Childrens Hospital (Dr. Marilyn Bull)
• Childrens Hospital Boston (Michele DeGrazia,
  NNP)
• KIM Conference (Kidz in Motion), annual child
  passenger safety conference with pre-conference
  focused on NICU topics

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Highlights from the AAP Clinical Report (2009)

• Car seat monitoring is recommended to determine
  physiologic maturity and stable cardiorespiratory
  function for infants lt 37 weeks gestational age
  (and with other risk factors for apnea,
  bradycardia, desaturation)
• Use the infants own car seat, according to
  manufacturer instructions (esp. recline angle!)
• Recommended duration 90-120 minutes, or length
  of travel (whichever is longer)

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Highlights from the AAP Clinical Report (2009)

• Use of car safety seats should be limited to
  travel to prevent complications (i.e.
  exacerbation of GERD)
• Conventional car seat with a semi-upright seating
  position should be used whenever possible
• Portable medical equipment
• Should be secured to prevent injury
• Monitors should have self-contained power source
  available that will last for twice the duration
  of travel

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Highlights from the AAP Clinical Report (2009)

• If an infant fails the monitoring period in a
  conventional car seat, use of a car bed (and
  another monitoring period) should be considered
• Before transitioning from a car bed, another
  monitoring in a car seat should be performed
• Limit use of other devices that may cause similar
  respiratory compromise (swings, carriers,
  backpacks)
• One parent should ride in the back seat with the
  car seat or car bed to observe the child
• Children should never be left unattended in their
  car seats (in or out of the vehicle)

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Car Bed Options
Angel Guard (birth 9 pounds, up to 21.5 inches)
Dream Ride (birth 20 pounds, 19-26 inches)
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Educational DVD for Hospitals

• One copy sent to each hospital in the state for
  educating staff on the car seat challenge
• Educational sessions being offered to interested
  NICUs and newborn nurseries around the state
• Request a DVD or training phomiak_at_miemss.org

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Car Seat Testing at Frederick Memorial
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History

• 2003-Initial policy written for Car Seat Testing
  in the SCN.
• 2006-Policy updated
• 2007-Policy updated to include testing in the NBN
  with an Order set, Car Seat Competency Tool for
  nursing staff, Information Sheet and Informed
  Consent for parents.

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Car Seat Testing in the NICU

• All nurses in the NICU have been trained to
  perform the car seat test.
• At present there are 3 certified car seat
  technicians, 1 is an instructor.
• All infants regardless of gestational age are
  tested prior to DC.
• Tested at least 1 hour after feeding.

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• Infant sits for at least 1 hour or the length of
  the car ride home, whichever is longer.
• Tested at least one to seven days prior to going
  home.
• If infant fails first test, infant is retested a
  few days later.
• If infant fails seat test twice, tested in a car
  bed provided by the hospital, in a side-lying or
  supine position.

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• Parents are counseled to avoid other upright
  positioning devices if infant is sent home in a
  car bed.
• An appointment is made with the Wellness Center
  for 2 weeks after DC to have the infant retested
  in their car seat by a CPS Instructor/nurse.

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Car Seat Testing in NBN

• All newborns less than 37 weeks gestation and/or
  less than 5 pounds have a car seat test before DC
  from the Birthplace or Pediatric Department.
• Newborn Nursery standing orders for car seat
  testing are initiated upon the birth of any
  newborn less than 37 weeks gestation and/or less
  than 5 pounds.

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• Parents are given an information sheet and
  informed consent and have the right to waive the
  car seat test.
• Parents provide car seat and infant is placed on
  cardiac/respiratory monitor and pulse oximeter in
  the NBN, at least 12 hours after birth.
• Test is done the same in NBN as in NICU.
• Core group of Mother-Baby nurses have been
  trained to do car seat testing.

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Parent Education

• If the car seat provided by the parents is to big
  for the infant, the hospital has a rental program
  with seats that start at 4 pounds for use until
  the infant has grown into their personal seat.
• Parent education packets on Post-Partum and the
  NICU provide parents with car seat information.
• Parents are also encouraged to have help with
  installing their car seats by certified
  technicians in the county.

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Training

• All nurses in the NICU are trained to do car seat
  testing and are signed off with the Competency
  Tool
• Core group of nurses on the Birthplace are
  trained to do car seat testing and signed off
  with the Competency Tool
• Will be a mandatory competency to complete at
  this years Competency Marathon.

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Retesting

• Infants that are discharged in a car bed are
  scheduled to be retested in 2 weeks after DC.
• Infants return to the FMH Wellness Center and
  are retested in their personal infant seat by a
  Certified Car Seat Instructor using a pulse
  oximeter that reads the infants oxygen levels
  and heart rate.
• Documentation at that time is done on the Safe
  Kids car seat inspection form due to the fact
  that we check the seat installation at that time
  as well.

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CommentsQuestions?