PEDIATRICS Vol. 104 No. 4
October 1999,
pp. 988-992
AMERICAN ACADEMY OF PEDIATRICS:
Transporting Children With Special Health Care Needs
Committee on Injury and Poison Prevention
 |
ABSTRACT |
Children with special health care needs should
have access to proper resources for safe transportation. This statement
reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of
children with specific health care needs, including those with a
tracheostomy, a spica cast, challenging behaviors, or muscle tone
abnormalities as well as those transported in wheelchairs.
All children, including those with special health care
needs, should have access to proper resources for safe transportation. Families and health care professionals should be informed of basic guidelines for selecting restraints, positioning children into them,
and securing these restraints in all types of vehicles, primarily the
family vehicle and school bus.1 Parents should be informed
of the resources available for proper restraint of children with
special health care needs during travel2 and thereby avoid
use of substandard products, makeshift restraint systems, or unsafe
methods of securement in motor vehicles.
Federal Motor Vehicle Safety Standard (FMVSS) 213, which regulates
design and performance of child restraint systems, does not recognize
that children with special needs may require the use of special
occupant restraint systems.3 The standard also does not
regulate specific design and performance criteria for occupant
protection devices that can provide safe seating for children with
disabilities. Crash testing of car safety seats that meet FMVSS 213 has
been done with test dummies representing children without special
medical problems that would affect restraint use in motor vehicles. The
biomechanical effects of a crash on test dummies representative of
children with special medical needs in any restraint system have not
been studied. Further research is needed, including development of such
test dummies by the National Highway Traffic Safety Administration to
address these concerns.
Children with special needs should not be exempt from the requirements
of each state's laws regarding child restraint and seat belt use.
Pediatricians can serve as resources for information to legislators,
policy makers, and law enforcement professionals, as well as school
officials who may be unaware of the importance and availability of
occupant protection systems for children with special needs.
| |
IMPORTANT CONSIDERATIONS |
- The rear seat is the safest place for all children, and
rear-facing car safety seats must never be placed in the front seat of
a vehicle that has a front passenger air bag. The impact of a deploying
air bag can severely injure or kill an infant or small child. Children
may also be at risk of injury if they are out of position or lie
against the door of a vehicle with a side air bag.
- For a child with special health care needs who requires
frequent observation during travel and for whom no adult is available to accompany the child in the back seat, an air bag on/off switch should be considered for the vehicle.
- Instructions provided by the manufacturer of the vehicle and
the manufacturer of the car safety seat must be followed.
- Plans for procurement of the most appropriate restraint and
training for the proper use of the device and its installation in the
vehicle should be incorporated into hospital discharge planning for all
children with special needs.4 Any child with a medical
problem should have a special care plan that includes what to do during
transport if a medical emergency occurs.
- Parents, health care professionals, and educators should be
encouraged to incorporate a child's special transportation needs into
the individual education plan developed with the school.
- There have been rapid changes in development and availability
of resources for safer transportation of children with special needs.
The current version of the American Academy of Pediatrics' "Car Seat Shopping Guide for Children With Special
Needs" should be a helpful reference for health care
professionals, parents, and school transportation
providers.5
- For additional information on transporting newborns or
premature infants and children with special needs on school buses, refer to the appropriate policy statements by the American Academy of
Pediatrics.6,7
| |
GUIDELINES FOR PROTECTION |
Although research has been limited, current information suggests
the following guidelines be adhered to when selecting an appropriate
occupant protection system and positioning a child with special needs
properly.
General: Infants and Young Children
- The child restraint system should meet FMVSS
213.3 Standard child restraint devices may be used for
many children with special health care needs, and, whenever possible, a
standard child restraint is the preferable choice. Use of a
"special" child restraint system for a child with health care needs
often may be postponed until a child exceeds the physical limitations
of a car safety seat.
- Car restraint systems should not be modified or used in a
manner other than that specified by the manufacturer unless the modified restraint system has been crash tested and has met all applicable Federal Motor Vehicle Safety Standards approved by the
National Highway Traffic Safety Administration.
- Infant-only car safety seats with capacity to recline are
useful for infants with many medical problems, especially respiratory conditions. Some convertible car safety seats also can be used in the
rear-facing position for children up to a weight of 13.5 kg (30 lb).
These restraints may be especially useful for children with poor head
and neck control.
- If the child's head drops forward while in a rear-facing car
safety seat because the position of the seat is too upright, a roll of
cloth can be wedged in the vehicle seat crease and under the car safety
seat base at the child's feet, so that the child reclines at no more
than a 45° angle or as specified in the manufacturer's instructions
(Fig 1).
- Premature and small infants should not be placed in car safety
seats with a harness-tray/shield combination or an armrest that could
directly contact the infant's neck or face during an impact.4,7,8
- Car safety seats with five-point harnesses anchored at both
shoulders, both hips, and between the legs, can be adjusted to provide
good upper torso support for many children with special needs.
General: Older Children and Adolescents
- When a child has outgrown a car safety seat, other
choices are available for proper and secure occupant restraint. Some
systems provide for full support for the child's head, neck, and back and accommodate children up to 47.2 kg (105 lb). Others, such as the
conventional E-Z-On Vest (E-Z-On Products, Jupiter, FL), can be used to
provide additional trunk support for a child who already has stable
neck control. Tethers, additional lap seat belts, or appropriate
tie-down systems are required for some of these devices and should
be a consideration for selection and proper use (Fig
2).
- Some older children with disabilities can be transported in a
special needs belt-positioning booster or a conventional
belt-positioning booster for trunk support. The booster seats help to
position the shoulder and lap belt across the child's chest and
pelvis.
- Conventional lap-shoulder belt systems may also be useful in
providing for chest restraint of some children with special needs. Lap-shoulder belts should be used properly. Lap belts should be low and
flat across the child's hips, and the shoulder belt should be snug
across the chest. If a lap belt lies on the child's abdomen or if a
shoulder belt rests on a child's neck, use of a belt-positioning booster seat will help assure proper placement of the belts. The shoulder belt should never be placed underneath the child's arm(s) or
behind the child's back.
| |
TRACHEOSTOMIES |
Infants and children with a tracheostomy should not use child
restraint systems with a harness-tray/shield combination or an armrest.
On sudden impact, the child could fall forward causing the tracheostomy
to contact the shield or armrest, possibly resulting in injury and a
blocked airway.9 A rear-facing car safety seat with a
three-point harness or a car safety seat with a five-point harness
should be selected for children with a tracheostomy.
| |
MUSCLE TONE ABNORMALITIES |
- For toddlers with poor head control, a convertible car
safety seat approved by the manufacturer for use in a semireclining position when facing forward may be beneficial.
- Crotch rolls, made with a rolled towel or a diaper, may be
added between the child's legs and the crotch strap to keep the hips
against the back of the seat and prevent the child from slumping forward in the seat. This modification should be used for any child who
cannot maintain appropriate posture.
- Lateral support may be provided with rolled blankets, towels,
or foam rolls (Fig 3).
- Soft padding that does not alter the function of the harness
may be positioned behind the neck and on either side of the head to
promote anatomic alignment. However, padding should never be placed
behind or under the child in the seat.10 Soft padding
(such as blankets, pillows, or soft foam) compresses on impact and can
prevent harness straps from maintaining a secure, tight fit on a
child's body (Fig 3).
- A foam roll or rolled blanket may be placed under a child's
knees to inhibit hypertonicity or opisthotonic posturing (Fig 3).
| |
PRONE AND SUPINE POSITIONING OF INFANTS |
Infants who must lie prone after surgical repair of
myelomeningocele or infants who must lie prone to maintain an open
airway, such as those with Pierre Robin sequence, may require a
restraint that allows prone positioning.5,11,12
View larger version (38K):
[in this window]
[in a new window]
|
Fig. 3.
Child in convertible car seat with soft padding behind the neck, on
either side of the head and along the sides to promote anatomic
alignment. Foam roll or rolled blanket may be placed under knees to
inhibit hypertonicity.
|
|
| |
SPICA CASTS |
- For children with spica casts, a specially modified
convertible car safety seat, the Spelcast (Snug Seat, Inc, Matthews,
NC), has cut-away sides and seat bottom that provide room for a
comfortable and snug fit into the restraint system (Fig
4). This seat fits infants up to a weight
of 9.0 kg (20 lb) (rear-facing position) and toddlers who weigh up to
18.0 kg (40 lb) (front-facing position).
- Many older toddlers and preschool and school-aged children in
body or hip spica casts have limited resources available for safe
transport in motor vehicles. One resource, the modified E-Z-On Vest,
has performed satisfactorily during dynamic crash testing with a test
dummy weighted to 47.2 kg (105 lb) and is available commercially. Two
sets of seat belts routed through the vest are used to secure the child
at the child's side against the vehicle seat. An ancillary belt loops
around the casted leg or legs at the knees and is routed through the
other seat belt (Fig 5). When it is not
possible to fit a child onto a vehicle seat, use of an ambulance for
transport is recommended. For lateral positioning on the vehicle seat
(eg, as required by a car bed restraint or the modified E-Z-On Vest),
position the child's head as far as possible from the side of the
vehicle (Fig 6).
| |
CHALLENGING BEHAVIOR |
- Older children with hyperactivity, autism, or emotional
problems may require a safety restraint that is less likely to be unbuckled by the child. High back booster seats with internal harnesses
that have seat belts routed underneath the seat base may be helpful in
reducing the child's likelihood of unbuckling the restraint during
travel. Large child car safety seats with a 5-point harness may be
required for children weighing over 40 lb who cannot be
restrained in a belt positioning booster seat with only a lap/shoulder
harness.
- Vests with rear back closure also may be helpful for use with
children who have behavioral problems that may interfere with safe
travel.5
| |
WHEELCHAIR TRANSPORTATION |
Any child who can assist with transfer or be "reasonably"
moved from a wheelchair, stroller, or special seating device to the
original manufacturer's forward-facing vehicle seat equipped with
dynamically-tested occupant restraints or be "reasonably" moved to
a child restraint system complying with FMVSS 213 requirement should be
so transferred for transportation. The unoccupied wheelchair also
should be secured adequately in the vehicle to prevent it from becoming
a dangerous projectile in the event of a sudden stop or
crash.13
Occupied wheelchair(s) should be secured in a forward-facing position.
Any occupied wheelchair should be secured with four-point tie-down
devices. Lap boards or metal or plastic trays attached to the
wheelchair or to adaptive equipment should be removed and secured
separately for transport. An occupant restraint system that has been
tested at 30 mph and 20G force conditions and that includes upper torso
restraint (ie, shoulder harness) and lower torso restraint (ie, a lap
belt over the pelvis) should be provided for each wheelchair-seated
occupant.14 Head bands should not be used to restrain the
child's head separately from the torso.
| |
EQUIPMENT TRANSPORTATION |
- When a child with special needs is in transit, ancillary
pieces of medical equipment (eg, walkers, crutches, oxygen tanks, monitors) should be secured on the vehicle floor; underneath a vehicle
seat or wheelchair; or to the bus seat, bus floor, or bus wall below
the window line so that they do not become a projectile during a crash
and strike an occupant.
- Electrical equipment for use during transit should have
portable self-contained power for twice the expected duration of the trip. For improved safety, lead acid batteries or electrically powered
wheelchairs or other mobile seating devices and respiratory systems
should be converted, when possible, to gel-cell or dry-cell batteries.
To house and protect batteries during everyday use, transportation, and
collision, the use of external battery boxes is recommended.
| |
RESOURCE AVAILABILITY |
The National Easter Seal Society (800-221-6827) can assist
identifying local community resources for procurement of specific restraint systems.5
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.
| |
REFERENCES |
-
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]
-
Stout JD,
Bull MJ,
Stroup KB
Safe transportation for children with disabilities.
Am J Occup Ther.
1989;
43:31-36 [Medline]
-
National Highway Traffic Safety Administration: Federal Motor Vehicle Safety Standards; child restraint systems; child restraint anchorage systems. Federal Register. 2127(1999)
-
American Academy of Pediatrics, Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge. 1999;104;986-987
-
American Academy of Pediatrics. Car Seat Shopping Guide for Children With Special Needs (brochure). Elk Grove Village, IL: American Academy of Pediatrics; 1998
-
American Academy of Pediatrics, Committee on Injury and Poison Prevention
School bus transportation of children with special needs.
Pediatrics.
1994;
93:129-130 [Abstract/Free Full Text]
-
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]
-
Weber K
Rear-facing restraint for small child passenger: a medical alert.
University of Michigan Transportation Res Inst Res.
1995;
25:12-17
-
Stroup KB,
Wylie P,
Bull MJ
Car seats for children with mechanically assisted ventilation.
Pediatrics.
1987;
80:290-292 [Abstract/Free Full Text]
-
Bull MJ,
Stroup KB,
Stout J,
Doll JP,
Jones J,
Feller N
Establishing a special needs car seat loan program.
Pediatrics.
1990;
85:540-547 [Abstract/Free Full Text]
-
Stroup KB, Weber K, Bull MJ. Safe Transportation Solutions for Children With Special Needs. In: 31st Proceedings of the American Association for Automotive Medicine; September 28-30, 1987; New Orleans, LA. Pages 297-307
-
Bull MJ,
Stroup KB,
Everly JS,
Weber K,
Doll J
Child safety seat use for infants with Pierre Robin sequence.
Arch Pediatr Adolesc Med.
1994;
148:301-305 [Abstract]
-
American Academy of Pediatrics, Committee on Injury and Poison Prevention
School transportation safety.
Pediatrics.
1996;
97:754-757 [Abstract/Free Full Text]
-
National Safety Council. National Standards for School Buses and School Bus Operations. Revised ed. Warrensburg, MO: Missouri Safety Center, Central Missouri State University; 1995
Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
Top
Abstract
References
