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PEDIATRICS Vol. 104 No. 4 October 1999, pp. 986-987

AMERICAN ACADEMY OF PEDIATRICS:
Safe Transportation of Newborns at Hospital Discharge

Committee on Injury and Poison Prevention

	ABSTRACT

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All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

All newborns discharged from hospitals should be transported home in car safety seats that meet Federal Motor Vehicle Safety Standard (FMVSS) 213 and that are selected to meet the specific transportation needs of healthy newborns, premature infants, or infants with special health care needs.

In 1996, 1780 children (newborns to 14 years of age) were killed, and 305 000 were injured as occupants in motor vehicles.¹ Of the fatalities, 60% were unrestrained. The fatality rate for infants was higher than any other age group, 4.4/100 000.² In 1996, 653 children (newborns through 4 years of age) were killed as occupants in motor vehicles. Of these fatalities, 52% were unrestrained.

The American Academy of Pediatrics (AAP) has made major contributions to child passenger safety, including contributions to the passage of legislation in all 50 states that requires the use of car safety seats or child restraint devices for infants and young children. Assuring that newborns are restrained properly when riding for the first time establishes the pattern for continued compliance with a measure that can save their lives or prevent serious injury. Correctly used car safety seats are 71% effective in preventing fatalities attributable to car crashes and 67% effective in preventing injury that requires hospitalization. With 100% correct use, about 53 000 injuries and 500 deaths could be prevented each year in the United States among children from birth to 4 years of age.³

	RECOMMENDATIONS

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1. In conjunction with their medical staff, all hospitals with services for newborns should develop policies for the discharge of newborns in car safety seats that are crash tested and meet the FMVSS 213. These policies should be developed in consultation with a car seat expert who has successfully completed the National Highway Traffic Safety Administration (NHTSA) 4-day course.⁴ Although the resources of hospitals and patients vary greatly, at discharge every newborn should be properly restrained in a car safety seat.
2. Pediatricians should work with these hospitals in establishing hospital policies that clearly define staff roles for each required task. Also, pediatricians should reinforce the need for compliance with these policies with both hospital staff and parents/guardians. Hospital policies related to newborns should include the following:
   • Methods by which expectant parents will be informed, before delivery, of the importance of using car safety seats and potential problems with vehicle incompatibility. Parents should be advised through prenatal classes, their obstetrical provider, or pediatric prenatal visits to obtain a car safety seat, properly secure it in their vehicle, and resolve compatibility issues before delivery. This is especially important because physicians frequently discharge infants after only a short hospital stay.
   • Designation of an individual responsible for implementing hospital policies and procedures related to discharge of newborns in car safety seats that are used properly. Hospital policy also should include designation of an individual or team specifically trained to assess the needs of infants with special health care needs with regard to the selection of the most appropriate child safety seat.^5-8 Hospitals should develop a policy to ensure provision of a period of observation in a car safety seat before hospital discharge for each infant born at <37 weeks' gestation to monitor for possible apnea, bradycardia, or oxygen desaturation.⁵
   • >Provision for periodic in-service education of staff responsible for parent and guardian education on correct use of car safety seats. Those responsible for training other hospital staff and parents and guardians should have successfully completed the NHTSA 4-day course.⁴
   • Provision of regular periodic review by a designated person who has completed the NHTSA 4-day course of all materials distributed to parents and guardians of newborns about proper car safety seat use. Hospitals should ensure that information is current, relevant, and accurate, with date of publication or revision noted.⁹
   • Provisions to make available an appropriate car safety seat by sale, short-term loan, or donation to parents before discharge if the parents are unable to provide their own. Hospitals should consider giving a low-cost infant car seat, which can also be used for generic instruction, to parents at discharge as a gift.
   • Assessment of the degree of compliance with the policies and procedures on discharge in child safety seats in routine quality assurance surveillance by hospital staff. Hospital staffs should take appropriate actions to correct deficiencies when present.

Admission orders for newborns should include an order written by a physician for parent instruction about use of child safety seats. This should be included as a part of standard admission orders to ensure its completion before discharge.

Discharge policies for newborns should include the following:

• Determination of the most appropriate car safety seat for each newborn according to maturity and medical condition by a designated hospital employee.
• Provision of information and training for parents and guardians should be presented before discharge on the generic issues related to correct use of car safety seats. Hands-on teaching including "return demonstration" should be a part of this instruction. The installation of a specific car seat in a specific car must be the parent's responsibility. Resources to address these issues are available from the AAP.^10,11
• A period of observation in a car safety seat before hospital discharge should be provided to each infant born at <37 weeks' gestation to monitor for possible apnea, bradycardia, or oxygen desaturation.⁵
• Pediatricians with other child health and safety advocates should work for coverage of appropriate child restraint systems as a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers. Until that time, hospitals are encouraged to have a giveaway or loan program for parents who cannot afford to purchase a car seat.

COMMITTEE ON INJURY AND POISON PREVENTION, 1999-2000
Marilyn Bull, MD, Chairperson
Phyllis Agran, MD, MPH
Danielle Laraque, MD
Susan H. Pollack, MD
Gary A. Smith, MD, DrPH
Howard R. Spivak, MD
Milton Tenenbein, MD
Susan B. Tully, MD

LIAISON REPRESENTATIVES
Ruth A. Brenner, MD, MPH
  National Institute of Child Health and Human Development
Stephanie Bryn, MPH
  Maternal and Child Health Bureau
Cheryl Neverman, MS
  National Highway Traffic Safety Administration
Richard A. Schieber, MD, MPH
  Centers for Disease Control and Prevention
Richard Stanwick, MD
  Canadian Paediatric Society
Deborah Tinsworth
  US Consumer Product Safety Commission
William P. Tully, MD
  Pediatric Orthopaedic Society of North America

SECTION LIAISON
Victor Garcia, MD
  Section on Surgery

CONSULTANT
Murray L. Katcher, MD, PhD

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	ABBREVIATIONS

FMVSS, Federal Motor Vehicle Safety Standard; AAP, American Academy of Pediatrics; NHTSA, National Highway Traffic Safety Administration.

	REFERENCES

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1. US Department of Transportation, National Highway Traffic Safety Administration. Traffic Safety Facts 1996. A Compilation of Motor Vehicle Crash Data From the Fatal Accident Reporting System and the General Estimates System. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 1997
2. Fingerhut LA, Annest JI, Baker SP, Injury mortality among children and teenagers in the United States: 1993. Inj Prev 1996; 2:93-94 [Medline]
3. An Evaluation of Child Passenger Safety: The Effectiveness and Benefits of Safety Seats. Springfield, VA: National Technical Information Service; 1986. DOT report DOT MS 806890
4. National Highway Traffic Safety Administration. Standardized Child Passenger Safety Training Program. Washington, DC: National Highway Traffic Safety Administration; 1998
5. American Academy of Pediatrics, Committee on Injury and Poison Prevention and Committee on Fetus and Newborn Safe transportation of premature and low birth weight infants. Pediatrics 1996; 97:758-760 [Abstract/Free Full Text]
6. American Academy of Pediatrics, Committee on Injury and Poison Prevention Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 1996; 97:761-763 [Abstract/Free Full Text]
7. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Transporting children with special health care needs. 1999;104:988-992
8. Summerfelt M, Spitzer A, Wallace E, et al. Kars/Special Kars. An Easter Seals' Model Program Training Manual. Chicago, IL: National Easter Seal Society; 1992
9. National Highway Traffic Safety Administration. Is This Child on the Road to Danger? Washington, DC: National Highway Traffic Safety Administration; 1997. DOT report DOT HS 808672
10. American Academy of Pediatrics. 1999 Family Shopping Guide to Car Seats (brochure). Elk Grove Village, IL: American Academy of Pediatrics; 1999
11. American Academy of Pediatrics. Car Seat Shopping Guide for Children With Speical Needs. (brochure). Elk Grove Village, IL: American Academy of Pediatrics; 1998

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