Chest wall bruising from 5-point car seat harness as a mimicker of child abuse.

Bruising rarely presents in infants younger than 9 months who are not ambulatory and is more prevalent among children beginning to walk, or "cruisers." We present the case of a healthy 3-month-old infant with asymptomatic, symmetric, bilateral, large bruises on the bony chest sparing the mid-chest/sternum with a negative non-accidental trauma work-up. The noted pattern of bruises matched the bilateral shoulder straps of a 5-point harness of the car seat belt designed for infants. Awareness of this unique pattern of bruises will help elicit a better-informed history to guide care in an appropriate setting.

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm.

OBJECTIVE: To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm. STUDY DESIGN: Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS. The primary outcome was a composite rate of death, 911 call-triggered transports, or readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening event, or brief resolved unexplained events within 30 days of discharge. Outcomes of infants born in the periods of CSTS and after discontinuation were compared. RESULTS: Twelve of 14 hospitals initially utilized CSTS and contributed patients to the CSTS period; 71.4% of neonatal intensive care unit (NICU) patients and 26.9% of non-NICU infants were screened. All hospitals participated in the discontinuation period; 0.1% was screened. Rates of the unadjusted primary outcome were 1.02% in infants in the CSTS period (n = 21 122) and 1.06% after discontinuation (n = 20 142) (P = .76). The aOR (95% CI) was 0.95 (0.75, 1.19). Statistically insignificant differences between periods were observed in components of the primary outcome, gestational age strata, NICU admission status groups, and other secondary analyses. CONCLUSIONS: Discontinuation of CSTS in a large integrated health care network was not associated with a change in 30-day postdischarge adverse outcomes. CSTS's value as a standard predischarge assessment deserves further evaluation.

Car seat impact on driver's sitting behavior and perceived discomfort during prolonged real driving on varied road types.

Prolonged driving under real conditions can entail discomfort linked to driving posture, seat design features, and road properties like whole-body vibrations (WBV). This study evaluated the effect of three different seats (S1 = soft; S2 = firm; S3 = soft with suspension system) on driver's sitting behavior and perceived discomfort on different road types in real driving conditions. Twenty-one participants drove the same 195 km itinerary alternating highway, city, country, and mountain segments. Throughout the driving sessions, Contact Pressure (CP), Contact Surface (CS), Seat Pressure Distribution Percentage (SPD%) and Repositioning Movements (RM) were recorded via two pressure mats installed on seat cushion and backrest. Moreover every 20 minutes, participants rated their whole-body and local discomfort. While the same increase in whole-body discomfort with driving time was observed for all three seats, S3 limited local perceived discomfort, especially in buttocks, thighs, neck, and upper back. The pressure profiles of the three seats were similar for CP, CS and RM on the backrest but differed on the seat cushion. The soft seats (S1 & S3) showed better pressure distribution, with lower SPD% than the firm seat (S2). All three showed highest CP and CS under the thighs. Road type also affected both CP and CS of all three seats, with significant differences appearing between early city, highway and country segments. In the light of these results, automotive manufacturers could enhance seat design for reduced driver discomfort by combining a soft seat cushion to reduce pressure peaks, a firm backrest to support the trunk, and a suspension system to minimize vibrations.

Trust in expert versus lay comments in online articles about spanking and car seat safety.

In this study, we experimentally examined parents' perceptions of scientific information about spanking, a controversial topic, and car seat safety, a consensus topic, presented in online news articles. Specifically, we tested whether parents of children ages 2 to 8 years would trust scientific experts (speaking from professional expertise) more than online lay commenters (speaking from personal experience). One hundred and eighty parents across 41 U.S. states were recruited online from Amazon's Mechanical Turk (124 mothers, 56 fathers; 74% White, 9% Black, 8% Latino, 8% Asian, and 1% other or multiple ethnicities). Parents were randomly assigned to read a news article with an expert discussing spanking research that varied by two conditions: The news article contained either anti-spanking lay comments or pro-spanking lay comments. All parents also read a second news article on car seat safety (a consensus topic). Between-condition analyses were used to compare perceptions of the comment conditions, and within-condition analyses were used to compare perceptions of the expert knowledge versus the comments and to compare perceptions of the spanking expert versus the car seat expert. Moderation analyses were used to compare parents' perceptions based on their attitudes toward spanking. Parents with positive attitudes toward spanking recognized pro-spanking comments as opinion, yet still found them more trustworthy than a scientist taking the opposite position. All parents perceived the car seat expert as trustworthy. The results highlight challenges in disseminating information about controversial topics to the public. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Variation in Car Seat Tolerance Screen Performance in Newborn Nurseries.

BACKGROUND: Currently, car seat tolerance screens (CSTSs) are recommended for all infants born prematurely in the United States. Although many late-preterm infants are cared for exclusively in newborn nurseries (NBNs), data on implementation of CSTS in nurseries are limited. Our objective for this study was to determine management strategies and potential variation in practice of CSTS in NBNs across the nation. METHODS: We surveyed NBNs across 35 states using the Better Outcomes through Research for Newborns (BORN) network to determine what percentage perform CSTSs, inclusion and failure criteria, performance characteristics, follow-up of failed CSTSs including use of car beds, and provider attitudes toward CSTS. RESULTS: Of the 84 NBNs surveyed, 90.5% performed predischarge CSTSs. The most common failure criteria were saturation <90%, bradycardia <80 beats per minute, and apnea >20 seconds. More than 55% noted hypotonia as an additional inclusion criterion for testing, and >34% tested any infant who had ever required supplemental oxygen. After an initial failed CSTS, >93% of NBNs retested in a car seat at a future time point, whereas only ∼1% automatically discharged infants in a car bed. When asked which infants should undergo predischarge CSTS, the most common recommendations by survey respondents included infants with hypotonia (83%), airway malformations (78%), hemodynamically significant congenital heart disease (63%), and prematurity (61%). CONCLUSIONS: There is a large degree of variability in implementation of CSTS in NBNs across the United States. Further guidance on screening practices and failure criteria is needed to inform future practice and policy.

Car Seat Tolerance Screening for Late-Preterm Infants.

BACKGROUND: The belief that late-preterm infants have similar cardiorespiratory maturity to term infants has led many institutions to limit car seat tolerance screens (CSTSs) to those born early preterm. The objective of this study was to evaluate the incidence and predictors of CSTS failure, focusing on late-preterm infants. METHODS: We performed a retrospective review of late-preterm infants born from 2013 to 2017 to identify the incidence and predictors of CSTS failure, focusing on location of admission. We performed multivariable linear regression to assess the effect of CSTS results on length of stay (LOS). RESULTS: We identified 918 subjects who underwent CSTSs, of whom 4.6% failed. Those infants who were admitted to both the NICU and nursery before discharge had the highest failure rate (8.5%). Of those who failed, 24% failed ≥2 CSTSs. Of these, 20% (all from the nursery) were found to have obstructive apnea and desaturations, and a total of 40% required supplemental oxygen for safe discharge from the hospital. Although crude LOS was longer for those who failed an initial CSTS, when accounting for location of admission, level of prematurity, and respiratory support requirements, the CSTS result was not a significant predictor of longer LOS. CONCLUSIONS: A concerning number of late-preterm infants demonstrated unstable respiratory status when placed in their car seat. Those who failed repeat CSTSs frequently had underlying respiratory morbidities that required escalation of care. Although further study is warranted, LOS was not associated with CSTS results but rather with the cardiorespiratory immaturity noted or discovered by performing a CSTS.

Post-discharge outcomes of failed car seat tolerance screens: A case-control and follow-up study.

BACKGROUND: Despite widespread implementation, limited data exists relating morbidity or adverse outcomes to Car Seat Tolerance Screen (CSTS) result in preterm and low birth weight (LBW) neonates. The objective of this study was to determine longer term post-discharge outcomes of infants who failed a CSTS. METHODS: We performed a case control study evaluating outcomes of infants born over one year who failed vs. passed an initial CSTS, utilizing both retrospective medical record review and parental survey data 2-3 years after discharge. Subjects were matched one case of failed CSTS to two controls who passed CSTS based on sex, gestational age, and BW. We performed bivariate analysis of clinical and demographic risk factors comparing those who passed vs. failed CSTS. RESULTS: We identified 19 subjects who failed and matched to 37 controls. Cases were significantly more likely to be diagnosed with obstructive sleep apnea (p = 0.027), asthma (p = 0.016), and be treated with albuterol (p = 0.008). We did not find differences in frequency of urgent care visits or hospital admissions between the groups. Although more of the cases were noted to have developmental delays, the difference was not statistically significant. CONCLUSION: This is the first study to evaluate longer term post-discharge outcomes of subjects having undergone CSTS. Subjects who failed CSTS had significantly increased incidence of respiratory diagnoses such as OSA and asthma than matched controls by 2-3 years after discharge. Larger studies are necessary to further evaluate these findings, but this does provide data that CSTS may be useful in identifying at risk neonates.

Car Seat Tolerance Screening in the Neonatal Intensive Care Unit: Failure Rates, Risk Factors, and Adverse Outcomes.

OBJECTIVE: To characterize the epidemiology of Car Seat Tolerance Screening (CSTS) failure and the association between test failure and all-cause 30-day postdischarge mortality or hospital readmission in a large, multicenter cohort of preterm infants receiving neonatal intensive care. STUDY DESIGN: This retrospective cohort study used the prospectively collected Optum Neonatal Database. Study infants were born at <37 weeks of gestation between 2010 and 2016. We identified independent predictors of CSTS failure and calculated the risk-adjusted odds of all-cause 30-day mortality or hospital readmission associated with test failure. RESULTS: Of 7899 infants cared for in 788 hospitals, 334 (4.2%) failed initial CSTS. Greater postmenstrual age at testing and African American race were independently associated with decreased failure risk. Any treatment with an antacid medication, concurrent use of caffeine or supplemental oxygen, and a history of failing a trial off respiratory support were associated with increased failure risk. The mean adjusted post-CSTS duration of hospitalization was 3.1 days longer (95% CI, 2.7-3.6) among the infants who failed the initial screening. Rates of 30-day all-cause mortality or readmission were higher among infants who failed the CSTS (2.4% vs 1.0%; P = .03); however, the difference was not significant after confounder adjustment (OR, 0.38; 95% CI, 0.11-1.31). CONCLUSION: CSTS failure was associated with longer post-test hospitalization but no difference in the risk-adjusted odds for 30-day mortality or hospital readmission. Whether CSTS failure unnecessarily prolongs hospitalization or results in appropriate care that prevents adverse postdischarge outcomes is unknown. Further research is needed to address this knowledge gap.

Predictors of Persistent Infant Car Seat Challenge Failure.

BACKGROUND: Premature and other at-risk infants can experience cardiorespiratory problems when positioned in their car seats. The American Academy of Pediatrics recommends that all premature and at-risk infants undergo a period of observation in their car seat to monitor for apnea, bradycardia, and oxygen desaturation before hospital discharge. This Infant Car Seat Challenge (ICSC) is used to determine readiness for infant travel in a car seat. Infants failing the ICSC are discharged home in car beds and referred for a follow-up screen in the outpatient clinic. PURPOSE: The purpose of this study was to identify predictors for infants failing the follow-up ICSC after hospital discharge. METHODS/SEARCH STRATEGY: A retrospective, cross-sectional study design was used to examine charts of 436 infants referred from across New England, to Boston Children's Hospital's, Center for Healthy Infant Lung Development clinic between August 2008 and May 2015 for a follow-up ICSC. FINDINGS/RESULTS: Infants who failed the follow-up ICSC had statistically significant lower weights (0.27 ± 0.14 kg, difference ± standard error, P = .03) and younger postmenstrual ages (0.9 ± 0.4 weeks, P = .03). History of a cardiac condition (odds ratio, 3.6; 95% confidence interval, 1.5-8.5; P = .005) and respiratory illness (odds ratio, 2.1; confidence interval, 1.1 to 4.2; P = .03) were significant predictors of ICSC failure. IMPLICATIONS FOR PRACTICE: A follow-up ICSC is recommended for the safe transition of infants from a car bed to a car seat. IMPLICATIONS FOR RESEARCH: Further research is needed to investigate the causes of ICSC failure among high-risk infant populations.

A traumatic pancreatic transection despite a child safety seat.

A 5-year-old boy sustained blunt abdominal trauma in a car crash. The buckle mechanism of the five-point harness of his child safety seat compressed his upper abdomen causing an isolated complete pancreatic rupture. Diagnosis was delayed due to subtle symptoms and normal initial findings. A CT scan confirmed diagnosis. An emergency limited central pancreatic resection was performed. The outcome was excellent.

Clinical Outcomes Associated with a Failed Infant Car Seat Challenge.

OBJECTIVE: To assess comorbid conditions and clinical outcomes among late preterm and low birth weight term infants (<2.5 kg) who failed the Infant Car Seat Challenge (ICSC) on the Mother-Baby Unit. STUDY DESIGN: This was a retrospective chart review of consecutive infants who failed ICSC on the Mother-Baby Unit and were subsequently admitted to the neonatal intensive care unit at Prentice Women's Hospital between January 1, 2009, and December 31, 2015. Regression models were used to estimate risk differences (RDs) with 95% CIs for factors related to length of stay. RESULTS: A total of 148 infants were studied (43% male; 37% delivered via cesarean). ICSC failure in the Mother-Baby Unit was due to desaturation, bradycardia, and tachypnea in 59%, 37%, and 4% of infants, respectively. During monitoring on the neonatal intensive care unit, 39% of infants experienced apnea (48% in preterm vs 17% in term infants) in the supine position, 19% received phototherapy, and 2% and 6.8% received nasogastric and thermoregulatory support, respectively. Univariate predictors of increased duration of stay (days) were younger gestational age, apnea, nasogastric support, intravenous fluids, and antibiotics (all P < .05). In multivariable analysis adjusted for gestational age and discharge weight, only apnea (RD, 4.87; 95% CI, 2.99-6.74; P < .001), administration of antibiotics (RD, 3.25; 95% CI, 0.29-6.21; P < .032), and intravenous fluid support (RD, 4.87; 95% CI, 0.076-9.66; P < .047) remained independent predictors of a longer duration of stay. CONCLUSION: Infants who failed ICSC were at risk for comorbid conditions that prolonged hospital stay beyond the neonatal intensive care unit observation period. Almost one-half of late preterm infants who failed ICSC had apnea events in the supine position.

A 3-month-old infant with recurrent apparent life-threatening events in a car seat.

A 3-month-old infant was brought to clinic for evaluation of recurrent apparent life-threatening events (ALTEs). Two ALTE episodes occurred while the infant was sleeping in a safety car seat. The first one occurred when he was 4 weeks old. His mother noticed that he was not breathing; he appeared limp with full body cyanosis. His mother picked him up from the car seat, and he started breathing spontaneously and without any sign of distress. His skin color returned to normal. He was evaluated at the ED where the physical examination was normal. He was hospitalized 1 day for observation. During this time, workup, including ECG and chest radiograph, was normal. The parents were instructed on cardiorespiratory resuscitation and recommended to change car seats. The infant was discharged with an apnea monitor. He wore the apnea monitor while in the car seat. A second similar episode occurred at 10 weeks of age for which he was seen at the ED and referred to our clinic for further evaluation. Neither episode was related to feeding.

Sudden unexpected infant deaths associated with car seats.

The purpose of this study was to investigate the frequency, circumstances, demographics, and causes of death of infants dying while seated in car safety seats. A retrospective review of a pediatric autopsy database at a specialist center over a 16-year period was undertaken to identify any infant deaths (aged <1 year), in whom death occurred while seated in a car safety seat. Fourteen car seat-associated deaths were identified from a total of 1,465 coronial infant autopsies (0.96 %). Four involved infants were being appropriately transported in the car seat, all of whom had a medical underlying cause of death (one infection and three congenital heart disease). The majority (10 cases; 70 %) occurred while car seats were being inappropriately used, outside of the car, including as an alternative to a cot or high-chair. Five of these infants died of explained causes, but four deaths remained unexplained after autopsy, and in one no cause of death was available. There were no cases of previously healthy infants dying unexpectedly in a car seat when it was being used appropriately, and in this series there were no cases of traumatic death associated with car seats, either during road traffic accidents, or from falling or being suspended from a car seat. Infant deaths in car seats are rare. These data support the recommendation that car seats be used only for transport and not as alternatives for cots or high-chairs. More research is required to investigate the effect of travel in car seats on infants with underlying conditions. There appears to be no increased risk of unexpected deaths of healthy infants transported appropriately in car seats.

Test-retest reliability of the infant car-seat challenge.

OBJECTIVE: To evaluate how a single infant car-seat challenge (ICSC) predicts subsequent respiratory physiology in premature infants. STUDY DESIGN: Prospective observational study of infants born at <37 weeks gestational age. Subjects underwent three ICSCs and we evaluated clinical characteristics, pass rate, and predictive value of a single ICSC pass. RESULT: Completed three ICSCs on 60 subjects. Seven failed initial ICSC (11.7%). Those who failed had lower birth weights. Of the 53 that initially passed, 47 passed two subsequent tests (89%). Those who passed an initial test and failed a subsequent test had lower weights at each ICSC. CONCLUSION: Our results indicate that passing an ICSC is highly predictive of passing subsequent ICSCs. Lower weights at birth and at the time of ICSC were associated with increased risk of failure. We recommend including low birth weight as an inclusion criterion for ICSCs.

Car seat safety for preterm neonates: implementation and testing parameters of the infant car seat challenge.

BACKGROUND: The American Academy of Pediatrics (AAP) recommends that all preterm neonates undergo a period of observation in a car safety seat before discharge, known as the Infant Car Seat Challenge (ICSC), to monitor for respiratory immaturity and the risk of adverse cardiopulmonary events in the upright position. However, no universal guidelines exist to define appropriate cutoffs for failure of the ICSC. We sought to evaluate regional neonatal intensive care unit (NICU) implementation of the ICSC and to evaluate variation in failure criteria. METHODS: We contacted level II and III nurseries/NICUs in New York/New England (n = 119) to determine if each performed ICSCs, their inclusion criteria, duration of testing, and failure criteria. RESULTS: We contacted 119 institutions and had an 87% response rate (n = 103). Of the institutions that responded, 89% (n = 89) perform ICSCs. Of these 89 with current protocols, 17% did not follow AAP guidelines to test all neonates born <37 weeks' gestation, and 45% did not follow guidelines for test duration. Despite wide variation, most units use thresholds for bradycardia of <80 bpm and desaturation of <90% to determine failure. CONCLUSIONS: Despite AAP guidelines, implementation of ICSCs for preterm neonates is not universal in the region studied. Variation in definition of ICSC failure means that neonates are receiving differential care, not on the basis of their clinical characteristics, but on which institution performs the test. We propose standardizing the test to all infants born at <37 weeks' gestation to a duration of at least 90 minutes, along with a failure threshold for bradycardia of <80 bpm for >10 seconds, and for saturation <90% for >10 seconds.