Restraints for Children with Special Healthcare Needs

1. Restraints for Children with Special Healthcare Needs Updated 7/29/19

2. Lecture Overview • Considerations for Restraint Selection • Basic Guidelines • Conventional Restraints • Specialized Restraints

3. Considerations for Restraint Selection • Child’s size and age • Medical condition or procedures • Optimal safety and positioning

4. Considerations for Restraint Selection • Recommended position during travel: • Does the child need to travel flat? Prone? Supine? • Does the child need to travel on his/her side? • Can the child breathe when sitting? • Can the child bend at the hips? • Can the child sit unsupported?

5. Considerations for Restraint Selection • Availability and/or affordability of restraints • Vehicle(s) • Other occupants • Family choices

6. Basic Guidelines • Avoid use of non-regulated products • Never modify structure unless crash tested with modification to meet FMVSS213 • Seemingly minor modifications can compromise performance of the restraint Infant using non-regulated support pad

7. Basic Guidelines • Minimize travel • Make frequent stops • Position child in back seat with adult Adult in back seat observing child

8. Basic Guidelines • On-off switch for air bag if necessary • Travel with medical care plan • For long trips, have list of health care providers and durable medical equipment providers, if applicable

9. Basic Guidelines • Securing medical equipment: • Place on floor of vehicle wedged with pillows, foam, or blankets • Secure with adjacent, unoccupied seat belts • Check vehicle owner’s manual about placing items under vehicle seat • Have enough power for equipment Apnea monitor being wedged under vehicle seat with towel roll

10. Conventional Restraints

11. Conventional Restraints • Use conventional restraints whenever possible • Easier to find • Easier to use • Less expensive • Rear-face as along as possible • Use CSS with higher-weight harness as long as possible

12. Conventional Restraints • Features helpful for children with special healthcare needs: • Multiple harness slots and crotch strap positions • Accessories, such as preemie inserts, or extra padding • Rear-facing weight limits up to 40 pounds (some seats are available with weights up to 50 pounds)

13. Conventional Restraints • Forward facing built-in recline or recline mechanism • Forward-facing harnesses up to 65-80 pounds • Boosters with weight limits up to 120 pounds and/or adjustability features

14. Rear-Facing Only Infants born prematurely positionedin rear-facing only child safety seats designed with positioning inserts

15. Rear-Facing Only Infants born prematurely positioned in car seats with blanket rolls

16. Rear-Facing Only 1 year old with achondroplasia

17. Rear-Facing to Higher Weights • month old child with Down syndrome

18. Rear-Facingto Higher Weights 3 year-old with developmental delays

19. Rear-Facingto Higher Weights Child approximately 14 months with an encephalocele

20. Forward-Facing Semi-Recline Car Seats: Product Listing 2019 Healthychildren.org

21. Forward-Facing Harnessto Higher Weight • Children who have outgrown convertible or combination seats and cannot sit unassisted or who have behavior issues • Can use towel rolls and/or soft cervical neck collar for positioning • Interim solution 5 year-old with cerebralpalsy and scoliosis

22. Soft Cervical Collars • Replace rigid neck collars with soft cervical collars during travel • Crash tests indicate rigid collars decrease neck flexion Child with soft cervical neck collar

23. Belt-PositioningBooster Seats 6 year old, who weighed about 100 pounds, in booster seat 10 year old with achondroplasia In booster seat with adjustable sides and head support

24. Vests and Harnesses 86Y-Harness from E-Z-ON Source: E-Z-ON 5 year old with autism in Ride Safer Vest 86Y-Harness with halo

25. Misuse Exercise

26. Misuse Child with autism who was getting out of her harness

27. Misuse 9 year-old, >50 pounds with achondroplasia

28. Misuse Infant with Down syndrome

29. Misuse 4 y.o., 41 lbs., 3’6” with cerebral palsy

30. Misuse Child with behavioral condition and who weighs >40 pounds

31. Misuse 2-year-old with autism

32. Misuse Infant with trach and medical equipment; mother concerned because infant’s head would fall forward

33. Misuse 8-month-old, 15 pounds with hydrocephalus; mother using head strap so baby’s head would not fall forward

34. Specialized Restraints

35. Specialized Restraints • Designed for CSHCN who: • Have outgrown conventional child restraint system and still require a five-point harness or positioning device and accessories to sit upright • Demonstrate severe behavioral problems • Usually ordered through local durable medical equipment (DME) provider • Third party payers may cover cost with documentation

36. Specialized Restraints NOTE: The seats presented in these slides may not be all inclusive and do not imply product endorsement.

37. Types of Specialized Restraints • Car Beds • Car Seats for Casts • Jefferson Rear Facing Car Seat • Large Medical Seats • Belt-Positioning Boosters • Vests and Harnesses

38. Car Beds • For infants who must lie down • Prematurity, LBW, apnea, Pierre Robin Sequence, osteogenesis imperfecta Dream Ride Hope Car Bed Angel Ride

39. Angel Ride Car Bed • < 9 pounds • < 21.5 inches • Supine • Right-side or prone position only if medically necessary • Replacement harness and covers • New owner began shipping bed in August 2019

40. Positioning: Angel Ride • Place baby on back • Bring pad and crotch strap through legs • Bring shoulder portion of harness over shoulders • Buckle mid-chest • Adjust to snug fit Baby supine in Angel Ride

41. Positioning: Angel Ride • If infant on right side, consult medical staff about padding under head to support head and maintain an open airway • Do NOT use pillows or other soft items to pad under head • DO NOT place padding under child’s torso or harness

42. Installation: Angel Ride • If installed with lap/shoulder belt, shoulder belt outside of belt guides • Head toward center • Middle back seating position or behind passenger • One seat belt routed across front of bed, under belt guides

43. Installation: Angel Ride • Extra set of loops to prevent back of restraint from flipping up • Attach loops to lap portion of vehicle seat belt

44. Dream Ride • Dorel • 5-20 pounds • 26 inches or less • Supine • Prone only on advice of doctor • Carrying handle

45. Positioning: Dream Ride • Place baby on back • Bring harness over shoulders • Bring crotch strap between legs • Buckle mid-chest height Illustration from Dream Ride instructions of harness

46. Positioning: Dream Ride • Tighten or loosen harness at buckle strap or harness strap • Thread free end of buckle or harness straps between adjustment slides and tighten • Free end of strap only comes back through one of the adjustment slides Illustration from Dream Ride instructions of harness strap being threaded between adjustment slides

47. Positioning: Dream Ride • Prone on written advice of physician • Do not place padding near face/head • Limited head space when prone • Will outgrow at 10-12 pounds when prone • Observe closely

48. Installation: Dream Ride • Install lengthwise in outboard or middle seating positions • Infant’s head should face center of vehicle • Can install with seat belt or lower anchors (depending on model) Fabric Loops

49. Installation: Dream Ride Can install behind the passenger or driver by changing the loops or lower anchors to the other side Moving fabric loops from one side of the bed to the other

50. Installation: Dream Ride • Seat belt installation: • Bring one seat belt through both fabric loops • Buckle • Lock and tighten seat belt