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Considerations for Restraint Selection
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Behavioral Challenges
Children who exhibit behaviors such as impulsiveness, distractibility, and short attention span which may be associated with conditions such as autism, attention deficit-hyperactivity disorder, or cognitive impairment may resist consistent use of child safety seats and prove to be serious distractions to drivers. Families may have to try a variety of seats to see which is the must difficult for the child to escape. Harness systems must be properly secured and snug. Child safety seats that have harness systems for use beyond 40 pounds may also prove useful.
An E-Z-ON Vest with back closure or a large medical seat may provide securement for older children.
Casts
Casts prevent a part of the body from moving so that it has time to heal. Casts are made from plaster or fiberglass and can be applied to treat a broken bone and conditions such as dislocated hip, or after a surgery that involves muscles and/or bones.
When a child has a cast, it is important to determine if the type of cast will affect the child's ability to bend at the hip and sit up. If a child cannot sit up because of the cast, it will be very difficult, if not impossible, to fit the child in a standard car seat. A special child safety seat or restraint will probably be necessary. Examples of special restraints for children in casts include car beds for infants, the Spelcast convertible seat for infants over 10 pounds and toddlers who weigh up to 40 pounds, and the modified E-Z-ON vest for children who are 2 years and older and weigh at least 20 pounds.
Here are illustrations of some casts that go above and below a child's s hips and prevent the child from sitting.
Under no circumstances should a child travel on a vehicle seat that is reclined back. On a reclined vehicle seat, the seat belts will not contact the child's body properly and the child could slide out and be seriously hurt. In some cases, even special restraints won't work and professional transportation such as an ambulance will be necessary.
If a child has a cast that doesn't prevent her from bending at the hip and sitting up, she can probably use a standard child restraint. However, make sure that the cast does not prevent the harness from buckling. For example, it is easier to buckle a five-point harness than a shield or tray harness around a thick-long leg cast. Here are illustrations of some casts that do not prevent a child from sitting up.
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| Short Leg Cast |
Long Leg Cast |
Long leg broomstick cast |
Cerebral Palsy
Cerebral Palsy (CP) is a group of disorders of movement and posture due to a non-progressive defect or lesion of the brain. Damage can occur before or after birth. Developmental delays in an infant or toddler are usually the first signs of cerebral palsy. Symptoms range from slight speech impairment to total inability to control body movements.
Since many children with CP experience poor head, neck, and trunk control, they benefit from riding rear-facing to higher weights. In a crash, forces are spread over the back of the child safety seat and the child's back. The child is at less risk for neck and spinal cord injuries.
Once a child outgrows a rear-facing seat and has to ride forward facing, the child may be better positioned if she rides in a convertible or forward facing only seat that can be semi-reclined. This position can help keep the child's head from falling forward. Rolled blankets or foam placed along each side of the child can assist with centering the head and torso.
Children who have poor upper body strength will require the support of an adaptive restraint or large medical seat once they outgrow a standard child safety seat. It is a good idea to work with a rehabilitation therapist to help select the adaptive restraint that best meets a child's positioning needs and assist with ordering the product. Since a large medical seat is much more expensive than a standard seat, a therapist can also help with efforts to secure funding through a third-party payer..
In some instances, a child with CP will require use of a wheelchair. Selection of a wheelchair should also be done under the guidance of a rehabilitation therapist. Many wheelchairs are not designed for transportation purposes. If possible, a child should be moved to an appropriate restraint system during travel. For more information on wheelchairs, including transit models of wheelchairs, visit www.wheelchairnet.com.
Some children with CP have orthopedic surgery and are in a cast post-operatively. Depending on the type of cast, the child may require use of an adaptive restraint until the cast is removed.
Low Birth Weight and Premature Infants
Low birth weight infants are those born weighing less than 2500 g (about five pounds) and can include full-term and premature infants. Premature infants are those who are born before 37 weeks. Due to their size, low birth weight and premature infants need to travel in child safety seats that fit their smaller bodies. This means that the harness system of the child safety seat will need to have smaller dimensions:
- The distance from the lowest set of harness slots to the bottom of the child safety seat should be short enough so that the harness is at or below the baby's shoulders.
- The distance from the crotch strap to the back of the seat should be short enough so that the baby's bottom is held back against the child safety seat and does not slide forward.
The smaller dimensions will help keep the baby secure in the seat. Generally an infant only seat will provide the best fit for a small baby.
Child safety seats that have shields or trays should be avoided. In a crash or sudden stop, the baby's head could hit the shield or tray.
Rolled receiving blankets or towels can be placed on both sides of the  baby to center him or her in the seat. If necessary, a small wash cloth or cloth diaper can be rolled and placed between the crotch strap and the baby's diaper area to prevent the baby from sliding. Do NOT add padding under or behind the baby.
In addition to finding a seat that fits a premature infant, it is important to evaluate the infant's respiratory status while he or she is sitting in the seat. This is important because some premature infants experience breathing problems when they are sitting semi-reclined in a child safety seat. The American Academy of Pediatrics recommends that premature infants be observed for breathing related problems before they are discharged from the hospital nursery. Those babies who experience difficulties may have to travel flat in a car bed that meets federal safety standards.
If an infant needs a car bed, check with the infant's physician to see when the he or she will be ready to travel in a rear-facing child safety seat.
Myelomeningocele
Myelomeningocele or spina bifida is a birth defect of the spine resulting from abnormal closure of the neural tube during formation of the central nervous system. At the location of opening, nerve development is adversely affected and the formation of bone, muscle, and skin around the cord impeded. A sac, called a cele, is created at the opening. The cele can be covered by a thin layer of nerve tissue and sometimes skin. Nerve damage varies and depends on the location of the cele.
Since initial treatment involves surgical repair of the cele, a car bed may be required during the post-operative period. A car bed or child safety seat with recline may be useful for children with hypoventilation. Many children with spina bifid can be positioned rear-facing to higher weights due to their smaller size, low tone, and/or larger head due to hydrocephalus. Older children may benefit from a large medical seat that provides additional positioning support. Use of a wheelchair may be necessary for some children with mobility needs.
Tracheostomy
A tracheostomy is the surgical operation of cutting into the trachea through the neck to allow passage of air. A "trach" tube is inserted into the opening and attached to oxygen or a ventilator. Some children who have tracheostomies are "technology dependant" and require life-support equipment at all times.
Avoid child safety seats with shields or trays. These could hit the trach during a crash or sudden stop.
Any medical equipment that accompanies the child should be secured. If the equipment uses batteries, it should have enough power for at least double the length of the trip.
An emergency plan should be in place in case the tracheostomy tube comes out during travel.
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