eLetters to:

FROM THE AMERICAN ACADEMY OF PEDIATRICS: Marilyn J. Bull, William A. Engle The Committee on Injury, Violence, and Poison Prevention and the Committee on Fetus and Newborn Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge Pediatrics 2009; 123: 1424-1429 [Abstract] [Full text] [PDF]

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eLetters published:

Overreaching

Arthur A Strauss   (20 May 2009)

Cardiopulmonary Monitoring in Car Safety Seats

William A. Engle, Marilyn J. Bull   (29 May 2009)

Lack of Evidence for Car Safety Seat Testing

James M. Greenberg, Scott Wexelblatt   (3 June 2009)

Evidence for Car Safety Seat Testing

William A. Engle, Marilyn J. Bull, MD, FAAP   (20 July 2009)

Overreaching 20 May 2009
Arthur A Strauss, Neonatologist Miller Children's Hospital, Long Beach CA Send letter to journal: Re: Overreaching astrauss{at}memorialcare.org Arthur A Strauss	The statement on the safe transportation of preterm infants continues to reinforce the myth of utility of pre-hospital discharge "car seat testing". There is no valid study to date that demonstrates that either normal or abnormal findings on a pneumogram or other testing of cardio-respiratory events (observation) has any relevence to what happens to a preterm infant when placed in a car seat for the ride home. Unless a study is performed that records continuous events while the infant is in the actual car seat positioned in the car for different time intervals - nothing can be stated about the supposition that one has anything to do with the other. Rather than inappropriately raising caretaker anxiety about the discharge or delaying the discharge for having an "abnormal test", time and effort would be better spent on making sure a preterm infant is ready for a safe discharge (no recent cardiorespiratory events, preparation of the parents about safe positioning and support for the infant's airway and the common sense notion about avoiding unnecessary travel, etc). Car seat testing is a notion that has found its way into the neonatal literature (one of a suggested list of late preterm infant discharge criteria) without evidence to support it. We can do better than this. Conflict of Interest: None declared
Cardiopulmonary Monitoring in Car Safety Seats 29 May 2009
William A. Engle, Neonatologist Riley Hospital for Children, Indiana University School of Medicine, Marilyn J. Bull Send letter to journal: Re: Cardiopulmonary Monitoring in Car Safety Seats wengle{at}iupui.edu William A. Engle, et al.	The letter written by Dr. Strauss outlines the need for additional research about the impact of cardiopulmonary events in low birth weight or small infants positioned in car safety seats. We appreciate the suggestion, and fully support the need for additional information to refine the clinical management of these infants. This clinical report is based on expert opinion and a number of clinical series demonstrating an increased rate of cardiopulmonary events in low birth weight infants while seated in car seats. These events are analogous to the events that are observed when monitoring such infants during neonatal intensive care. For significant events occurring in the intensive care setting, low birth weight infants may require interventions such as tactile stimulation, or, in some cases, resuscitation with supplemental oxygen, medications or a manual resuscitator. Such events, especially if unexpected or new, will result in additional investigation to determine a cause (i.e. polysomnogram, evaluation for sepsis or gastroesophageal reflux, echocardiography, etc.). Because low birth weight infants who are nearing discharge from the hospital are often relatively hypotonic compared to term infants and have a predisposition for apnea and cardiopulmonary complications of prematurity, it is reasonable to assess whether these infants have such events when placed in a new position that could cause airway obstruction or other physiologic stress, such as that in a car seat. If events occur in a car seat, like events in the intensive care setting, investigation about the cause and interventions may similarly be a reasonable course of action. We believe it is incumbent on clinicians to ensure that infants in car seats are as physiologically and clinically stable as are infants in their crib. We thank Dr. Strauss for his comments and urge investigators to further address the value of cardiopulmonary monitoring of low birth weight infants in car seats. Conflict of Interest: None declared
Lack of Evidence for Car Safety Seat Testing 3 June 2009
James M. Greenberg, Director, Division of Neonatology Cincinnati Children's Hospital Medical Center, Scott Wexelblatt Send letter to journal: Re: Lack of Evidence for Car Safety Seat Testing james.greenberg{at}cchmc.org James M. Greenberg, et al.	The value of the infant car seat to reduce the risk of death or injury attributable to motor vehicle accidents is well documented. It is also clear that infants, especially those born prior to 37 weeks gestation have a heightened risk of proximal airway obstruction, apnea, cyanotic episodes and bradycardia. The American Academy of Pediatrics continues to support the notion of car safety seat monitoring prior to hospital discharge to demonstrate physiologic maturity and stable cardiorespiratory function (1). However, no specific recommendations regarding the nature of such monitoring are provided. As the authors of the Guideline point out, additional research is needed to determine how health care providers might interpret the data from a car safety seat monitoring session. This places those responsible for ensuring the safe discharge of a neonate from the intensive care nursery in a tenuous position. We are encouraged to test for stability, but have no useful way to define stability. This predicament has predictably led to a proliferation of car safety seat monitoring protocols in our regional hospitals, some lasting for many hours. Pass/fail criteria are arbitrary at best. Those who fail are simply retested until they pass. Those who persistently fail are recommended for a car bed. However, recent published data demonstrates that such patients do not fare any better with these devices Salhab et al (2) reported increasing frequency of desaturation episodes beyond approximately 50 minutes when infants were appropriately positioned in a car safety seat or car bed. We believe that the Academy’s recommendation to conduct “a period of observation for 90-120 minutes or the duration of travel, whichever is longer” is unwarranted and lacks a sound physiologic basis. There is simply no evidence that extended periods of car safety seat monitoring prior to discharge reduce risk of unanticipated cardiopulmonary compromise. Such testing may in fact, inadvertently convey a false sense of security for parents (3). Patient care staff time devoted to testing is much better spent orienting parents and caregivers to proper car safety seat positioning, installation, and observation of the infant. Based upon clinical experience and data presented by Salhab et al, it is unlikely that any preterm infant ready for discharge from an NICU is sufficiently mature to safely remain in a car safety seat for more than 30 -40 minutes. We do agree that parents must receive careful orientation and instruction including information regarding how to minimize head flexion. Further, infants in car safety seats should be placed in the back seat under the direct observation of an adult caregiver. When car travel beyond 30 minutes duration is unavoidable, regular stops to reposition the infant and minimize head flexion must be included, even if inconvenient. While automobile travel is a fact of modern life, we cannot avoid the reality that newborn human infants, especially those born before 37 weeks gestation have not experienced sufficient evolutionary time for adaptation. 1. Bull MJ, Engle WA, the Committee on Injury Violence, and Poison Prevention and the Committee on Fetus and Newborn. Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge. Pediatrics 2009;123:1424-1429. 2. Salhab WA, Khattak A, Tyson JE, et al. Car Seat or Car Bed for Very Low Birth Weight Infants at Discharge Home. J. Pediatr. 2007;150(3):224-228 3. Greenberg JM. The Challenge of Car Seats. J. Pediatr. 2007;150(3):215- 6. Conflict of Interest: None declared
Evidence for Car Safety Seat Testing 20 July 2009
William A. Engle, Neonatologist Indiana University School of Medicine, Marilyn J. Bull, MD, FAAP Send letter to journal: Re: Evidence for Car Safety Seat Testing wengle{at}iupui.edu William A. Engle, et al.	We thank Dr. Greenberg for his comments. He raises several important issues about the duration of car seat monitoring and use of car beds. Dr. Greenberg points out that the incidence of cardiopulmonary events experienced by preterm infants studied in car seats and car beds was similar. [Salhab] Furthermore, the longer an infant is in a car seat or car bed, there is a higher risk of such events. Not all preterm infants had cardiopulmonary events in both car seats and car beds; some infants only had events in one device, but not the other. This suggests that car restraint selection should be individualized. One solution to reduce the number of cardiopulmonary events in car restraint devices, as Dr. Greenberg suggests, is to educate families about the problem and limit the duration of exposure to car restraint devices to 30 minutes. Unfortunately, some infants experience events before 30 minutes of car restraint use. We agree that it would be ideal to limit travel for at risk children as much as possible until they are more physiologically stable and that they be observed by a second adult in the back seat whenever possible; however, such requirements are not feasible for some families. Importantly, car seat testing has been recommended to identify those at risk infants who develop cardiopulmonary events while positioned in a car restraint device. Car restraint studies have shown that some infants have events as long as 90-120 minutes after being positioned. (Salhab) Thus, 90-120 minutes was recommended for car seat testing. Because data is limited about time of events after 90 minutes of car seat use, additional study is needed and encouraged. If infants in car restraint devices have cardiopulmonary events, we believe that investigations and/or interventions to reduce the frequency of events is warranted. In the clinical report, it is suggested that use of a car bed; supplemental oxygen; continued hospitalization or further medical assessment be considered for infants experiencing cardiopulmonary events. The extent of the investigation or interventions must be individualized for the specific infant depending on the cause for such events (such as airway obstruction, aspiration, insufficient cardiopulmonary reserve) and response to interventions. As Dr. Greenberg suggests, an infant who has events in a car seat may also have events in a car bed. For infants placed in a car bed, as described in the clinical report, a period of cardiopulmonary monitoring before travel is also suggested. If such infants have no events, additional investigation may not be necessary. However, and depending on the cause for the events, additional study or treatment (such as oxypneumocardiogram, investigations to detect gastroesophageal reflux, supplemental oxygen) may be warranted. Prolonged use of car safety seats is discouraged. It is also important that infants in car safety seats be observed while seated in such devices as much as practically possible. We agree with Dr. Greenberg that these concepts are best taught to parents and families by knowledgeable and expert hospital staff during the discharge education process. William A. Engle, MD, FAAP Marilyn J. Bull, MD, FAAP Salhab WA, Khattak A, Tyson JE, et al. Car Seat or Car Bed for Very Low Birth Weight Infants at Discharge Home. J. Pediatr. 2007;150(3):224- 228 Conflict of Interest: None declared