The Q&A format for this article was drawn from a conference webinar held in November, during which Barbara DiGirolamo of Boston Children’s Hospital reviewed the types of situations that arise when transporting children with special needs, as well as the CRs that are available to ensure these children continue to ride safely. DiGirolamo, a CPST-I and STAC (Safe Travel for All Children)-certified instructor, draws from her experience fitting children with a variety of special needs with suitable CR systems.
SRN: Can children with casts ride in CRs?
DiGirolamo: Yes, certainly. When determining the appropriate CR, be sure to consider the child’s casted weight. A car seat with low sides is needed if the child has a hip spica cast (in which the legs are splayed) or some other type, like a “Statue of Liberty” cast (for clavicle repair surgery).
When these casts can’t be used with a conventional CR model, special needs options are available from Etac (formerly Convaid|R82), Inspired by Drive (formerly Columbia Medical), and Merritt Manufacturing. Look for models just for spica casts or that have accessories that can be added to accommodate casts. For longer body casts, we use the EZ-ON Modified Laydown Vest, a device that meets FMVSS 213 that allows the child to ride lying down across a rear seat bench.
SRN: What do you recommend when children act out in extreme ways when in the car?
DiGirolamo: First, be sure to completely explore behavior modification approaches, such as providing positive reinforcement for good behavior and identifying/eliminating any potential triggers.
Be sure to consider child sensitivities and triggers before jumping to conclusions about how the child rides. For instance, some children have sensory issues related to how fabrics feel against their skin, so it may help to try a car seat with padding made of a different type of material. It’s possible for a simple change in sensory stimulus, which may not seem to be significant to someone without sensitivities, to make a huge difference in how a particular child behaves.
Although behavior management techniques can often be used successfully with children with conditions like autism, Fragile X, and attention deficit disorder, some children continue to resist getting into or staying in a car seat despite these efforts. For such situations, look for a car seat with a buckle that’s relatively difficult to release. Staying in the five-point harness stage as long as possible is important for these children, as it will be even easier to unbuckle the seat belt when riding in a booster seat. An EZ-ON Vest with a back-closure zipper or a Roosevelt car seat used with a manufacturer-supplied buckle guard and chest-clip guard may be worth considering.
SRN: What CR works best for children who have conditions that make breathing difficult?
DiGirolamo: For children who need to have their airway remain as open as possible, staying rear facing in a reclined position as long as possible is especially important, so look for a convertible model with an upper weight limit of 45 or even 50 pounds.
For premature or small babies who experience apnea or oxygen desaturation when tested in their rear-facing car seat, a car bed may be indicated. For very small babies (9 pounds or less), Merritt Manufacturing offers the Angel Ride Car Bed. Larger babies who need to ride lying flat can use the Safety 1st Dream Ride LATCH or Merritt Manufacturing’s Hope Car Bed (check instructions for model limits).
Children with breathing issues who are too big to ride rear facing may benefit from a forward-facing car seat that can be set to a semi-reclined position. The listing of car seats at www.healthychildren.org (Safety & Prevention/On The Go) indicates for each convertible, all-in-1, or combination CR whether a reclined position is an option when in forward-facing harness mode. Several may be reclined when forward facing.
If a child has a trach tube to help with breathing, caregivers are often concerned that a car seat’s harness will disrupt the tube. The caregiver must understand that a child is far safer when riding in a five-point harness, and this protection is crucial when a child has a trach. So, while they should certainly be watchful, caregivers should make sure their child always rides in a properly fitted car seat; rear-facing is ideal.
Also, remember that any oxygen tanks or machines used by the child should be secured in the car so they cannot become a projectile in a crash. Use a seat belt to secure equipment, or place it on the floor of the vehicle (ideally, pinned under the front seat, though always check the vehicle instructions for underseat restrictions due to air bag sensors or other wiring that may be present).
SRN: Can facial abnormalities affect CR use?
DiGirolamo: In some cases, conditions that result in facial abnormalities, such as Pierre-Robin Syndrome (in which the lower jaw is underdeveloped, causing the tongue to fall back into the child’s throat), may affect a child’s breathing, so the information I shared in my previous answer applies. Some conditions require placing asymmetrical padding alongside the child (though not under the child or the harness). A car bed might be needed (particularly an Angel Ride or Hope Car Bed, if the child must be positioned on his/her side).
SRN: What other childhood conditions do you commonly see that affect CPS?
DiGirolamo: Obesity is an issue; a third of U.S. children are obese. Fortunately, some of today’s conventional car seats can be used to hold heavy children as they get older. Selecting a model with wider dimensions is a good idea, and one with lower sides can be helpful when a caregiver must lift a heavy child into the CR. Several models have a 50-pound rear-facing weight limit. While many models can be used forward facing to 65 pounds, today there are far fewer that may be used above that weight than there were in the past; among models currently for sale, only the Maxi-Cosi Pria 85, with an upper child-weight limit of 85 pounds, is allowed for use over 65 pounds.
Of course, the main concern is that these children may transition out of a car seat too soon. When they outgrow a conventional CR, but a booster seat or seat belt is still not appropriate, an EZ-ON Vest is a good option, since it allows kids to stay safely restrained up to 168 pounds and custom sizing is available. Another option is the Safe Traffic System Ride Safer Travel Vest, which is now offered in size extra-large for children weighing up to 110 pounds. However, using either of these vests may require special tethering.