Transporting Children With Special Health Care Needs

Federal Motor Vehicle Safety Standard (FMVSS) 213 “Child restraints” specifies performance and labeling requirements for child safety seats. Any child safety seat purchased should be labeled to indicate it has met safety standard 213. These seats are required to meet Standard 213 while secured to the standard vehicle seat using only the standard vehicle lap belt.

*Special needs seats are excluded from child seat attachment requirements.

Child restraints designed for use by children with special physical needs are exempt from the requirement of being secured to a seat using only the standard vehicle lap belt. These special needs restraints may use an extra tether strap to secure them to the vehicle seat. While FMVSS 213 regulates design and performance of child restraint systems, it does not recognize that children with special needs may require the use of special occupant restraint systems. The standard also does not regulate specific design and performance criteria for occupant protection devices that can provide safe seating for children with disabilities.

Nevertheless, children with special health care needs should have access to proper resources for safe transportation. There are many child safety seats and other types of adaptive equipment that can be used to safely transport children with special needs. The following guidelines, recommended by the American Academy of Pediatrics, are just some suggestions for protecting children with specific health care needs, including those with tracheotomies, a spica casts, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs.

IDENTIFICATION AND USE OF SPECIAL NEEDS RESTRAINTS

1. The parent of a child with special needs who believes the child cannot safely be transported in a regular child safety seat should consult with their medical care provider about the most appropriate device for their child before purchasing a seat. The medical provider can recommend the best restraint for the child’s needs. For a complete list of special needs seats, see the attached listing

2. All child safety seats should be installed in the rear of the vehicle, regardless of whether it is a special needs or regular child safety seat. The rear seat is the safest place for all children. No type of restraint, including special needs restraints and rear-facing car safety seats, should ever be placed in the front seat of a vehicle that has a front passenger or side door 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.

3. If you are the parent of a child with special health care needs who requires frequent observation during travel, and you do not have another adult who can monitor the child in the back seat, you may consider putting the child in the front seat. This is only a consideration if your vehicle does not have an air bag. Front seat positioning is only possible when the vehicle is equipped with a switch that allows the air bag to be turned off.

4. When installing the seat, follow the manufacturer’s Instructions as closely as possible. Anyone who wishes to determine whether or not they have correctly installed the restraint should go to a permanent fitting station to have the installation checked. To locate a permanent fitting station in your area, go to www.safeny.com or call 877-459-9189.

5. Parents of school age special needs children should also determine whether or not their child's special transportation needs have been incorporated into the individual education plan developed especially for their child.

The American Academy of Pediatrics recommends the following guidelines to protect children with special needs as they are being transported:

Infants and Young Children

1. As previously noted, the child restraint system should meet FMVSS 213. Frequently standard child restraint devices can be used for many children with special health care needs, and, whenever possible, this is the choice of preference. Sometimes the use of a special needs child restraint system may be postponed until a child exceeds the physical limitations of a car safety seat.

2. 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.

3. 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 30 pounds. These restraints may be especially useful for children with poor head and neck control.

4. 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. See Figure 1 below.

(Fig. 1) Rear-facing seat with wedge to recline seat at a 45° tilt.

5. 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.

6. 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

1. 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 105 pounds. 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. (See Figure 2.)

(Fig. 2) Large child forward-facing safety seat with tether anchored to vehicle.

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.

3. 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. 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

1. 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.

2. 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.

3. Lateral support may be provided with rolled blankets, towels, or foam rolls. (See Figure 3.)

(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.

4. 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. 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. (See Figure 3.)

5. A foam roll or rolled blanket may be placed under a child's knees to inhibit hypertonicity or opisthotonic posturing. (See Figure 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.

SPICA CASTS

1. 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. (See Figure 4.) This seat fits infants up to a weight of 20 pounds (rear-facing position) and toddlers who weigh up to 40 pounds (front-facing position).

(Fig. 4) Child with spica cast seated in modified seat with cut-away sides and seat bottom.

2. 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 105 pounds 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. (See Figure 5.)

(Fig.5) Child with modified E-Z-On Vest (E-Z-On Products, Inc, Jupiter, FL).

3. 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 (e.g., 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. (See Figure 6.)

(Fig. 6) Infant positioned supine in the Ultra Dream Ride car bed (Cosco, Columbus, IN).

CHALLENGING BEHAVIOR

1. 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 pounds who cannot be restrained in a belt positioning booster seat with only a lap/shoulder harness.

2. Vests with rear back closure also may be helpful for use with children who have behavioral problems that may interfere with safe travel.

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.

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 (i.e., shoulder harness) and lower torso restraint (i.e., a lap belt over the pelvis) should be provided for each wheelchair-seated occupant. Head bands should not be used to restrain the child's head separately from the torso.