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Needs: Comparing Recommendations and Practice

WHAT’S KNOWN ON THIS SUBJECT: The AAP published (1999) and reaffirmed (2006) guidelines for the transportation of CSHCN. The implementation of these guidelines has never been evaluated. Previous studies have evaluated the transport of CSHCN in other countries or therapists’ experience with the use of specialized medical seats.

WHAT THIS STUDY ADDS: This study helps the pediatric community better understand the transportation practices of caregivers of CSHCN. Our study reinforces recommended transportation practices and provides resources for the practitioner to improve the safety of CSHCN.

abstract

OBJECTIVE:We compare the use of the American Academy of Pediat-rics (AAP) guidelines for the safe transportation of children with spe-cial health care needs (CSHCN) with reported and observed practices.

METHODS:This observational study was based on a convenience sam-ple of vehicles exiting the garage of a tertiary children’s hospital. Cer-tified child passenger safety technicians with a health care back-ground and specialized training in the transportation of CSHCN gathered the driver’s demographic information and the child’s re-ported medical condition, weight, age, clinic visited, and relation to the driver. The safety technicians observed the car safety seat (CSS) type, vehicle seating position, and if the child required postural support.

RESULTS:During the study, 275 drivers transporting 294 CSHCN were observed. Overall, most drivers complied with AAP recommendations by using a standard CSS seat (75.4%). Among the seats evaluated, 241 (82.0%) were the appropriate choice, but only 75 (26.8%) of 280 as-sessed had no misuses. Approximately 24% of the drivers modified the CSS, and 19.4% of the children would have benefited from additional body-positioning support. Only 8% of medical equipment was properly secured.

CONCLUSIONS:Although most drivers seemed to choose the appropri-ate seat, many had at least 1 misuse. Drivers complied with most AAP recommendations; however, some deviated to facilitate care of the child during transport. Discussions with parents or caregivers about the proper transportation of CSHCN and referrals to child passenger safety technicians with special training may improve safety, care, and comfort in the vehicle.Pediatrics2009;124:596–603

CONTRIBUTORS:Joseph O’Neil, MD, MPH, FAAP,a,bJanell

Yonkman, MS, OTR,bJudith Talty, BA,band Marilyn J. Bull, MD,

FAAPa,b

aSection of Developmental Pediatrics, Department of Pediatrics,

andbAutomotive Safety Program, Riley Hospital for Children,

Indiana University School of Medicine, Indianapolis, Indiana

KEY WORDS

child passenger safety, children with special health care needs, safe transportation, car safety seats

ABBREVIATIONS

AAP—American Academy of Pediatrics CSHCN— children with special health care needs CSS— car safety seat

CPST— child passenger safety technician FMVSS—Federal Motor Vehicle Safety Standards NHTSA—National Highway Traffic Safety Administration

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1124

doi:10.1542/peds.2008-1124

Accepted for publication Dec 12, 2008

Address correspondence to Joseph O’Neil, MD, MPH, FAAP, Riley Hospital for Children, 702 Barnhill Dr, Room 1601, Indianapolis, IN 46202. E-mail: joeoneil@iupui.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2009 by the American Academy of Pediatrics

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Children with special health care needs (CSHCN) have the same or greater need for access to school, medical facilities, stores, recreation, and home as other children. However, because of medical, physical, or behav-ioral problems, these children often require more assistance during trans-portation than children with typical needs. Parents and caregivers are re-sponsible for the safe transportation of their CSHCN. These drivers may ex-perience difficulty in selecting the proper car safety seat (CSS) and un-derstanding the instructions for its proper installation and use.1Previous

evaluation of child occupant restraint use among CSHCN has shown a high prevalence of misuse.2 Parents and

caregivers may seek guidance on safe transportation from physicians, nurses, and physical, occupational, or rehabilitation therapists. Guidelines for the safe transportation of CSHCN were published by the American Acad-emy of Pediatrics’ (AAP) Committee on Injury and Poison Prevention in Pediat-rics in 1999 and reaffirmed May 1, 2006,3and in the AAP Parenting Corner

Q&A: Transporting Children With Spe-cial Needs.4 A compilation of these

guidelines is shown in Table 1. The im-plementation of these guidelines has never been evaluated. This article com-pares the use of these guidelines with the reported and observed practices among drivers who transport CSHCN.

METHODS

This was an observational study based on a convenience sample of vehicles exiting the Riley Hospital for Children outpatient parking garage. The AAP guidelines3 for transporting CSHCN

served as a basis to develop survey questions.

Surveys were conducted weekdays from 10:00AMto 4:00PMbetween Octo-ber 2005 and August 2006. As each ve-hicle (nonprofessional transport)

ex-ited the garage, the driver was asked if they were transporting CSHCN. If yes, the study was explained and they were invited to participate. As an incentive, the study participants received a gift certificate and paid parking for the day.

Certified child passenger safety tech-nicians (CPST) with a health care back-ground and specialized training in the transportation of CSHCN made all the observations and administered the surveys. Information was collected on the driver demographics, the child’s reported medical condition, weight, age, clinic visited, and relation to the driver. The diagnoses were catego-rized into behavioral/developmental, neurologic/neuromuscular, genetic disorder/chromosomal abnormality, and other. Drivers were also asked if they ever placed CSHCN in the front-seat passenger position to meet the immediate needs of the child during transport and if the seat was pushed all the way back or the front passenger-side airbag deactivated. The drivers were also asked if they ever modified the CSS to meet the needs of the CSHCN. Finally, the drivers were asked if they limit travel or have another per-son in the vehicle to assist in the care of the child.

The restraint type used by the child passengers and the vehicle seating po-sition were recorded. For both stan-dard CSS and specialized medical seats, the use of a top tether was

noted. The CSS choice was categorized for a child by age and/or weight. The categories were: birth to 11 months of age or 0 to 19 lb, 1 to 3 years of age or 20 to 39 lb, 4 to 7 years of age or 40 to 80 lb, 8 to 12 years of age, and ⱖ13 years of age. The child must have been either in the stated age range or weight range. The children were clas-sified strictly from left to right in the table. That is, if their age or weight met the criteria for the first category, that was their classification. If they failed category criteria, they were compared with the next category criteria. Head, neck, and trunk control was observed. If the child had poor head control, leaned to 1 side, or slumped forward, the observers noted whether the car seat provided adequate support or if supplemental head or trunk support was provided. An overall assessment by a CPST was made to determine if the CSS was appropriate for their needs or if there was critical misuse. Critical misuses were defined as those mis-uses that can reasonably be expected to raise the risk of injury in the event of a crash.5The method of securing

med-ical equipment in the vehicle was also evaluated. Drivers who had misuses identified were given information on proper CSS use, a referral to a CPST, or a new CSS or specialized medical seat with instruction.

Descriptive statistics were used to present the CSHCN and driver charac-teristics. Logistic regression models, TABLE 1 Recommendations for Transportation of CSHCN in Motor Vehicles

1. Whenever possible, a caregiver who transports CSHCN should use a standard CSS that meets or exceeds FMVSS 213.6

2. If lateral support is needed, it can be provided with rolled blankets and towels, but these additions to the seat should not affect the fit of the harness system of the CSS.

3. The CSS restraints should not be modified unless that modified system has been crash tested. 4. If a child must ride in the front seat and there is a passenger-side airbag, the driver should consider

turning this airbag off. Also, the vehicle seat should be moved as far back as possible in the vehicle. 5. All medical equipment should be secured on the vehicle floor or under the seat in front of the child so

that it does not become a projectile during a crash and strike an occupant.

6. Caregivers should limit travel or provide an adult who is trained to handle emergencies to ride in the back seat to attend to the medically fragile child if needed.

Adapted from AAP guidelines.

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with appropriate seat selection and with restraint misuse. SAS 9.1.3 (SAS Institute, Inc, Cary, NC) was used to an-alyze the data. The protocol was ap-proved by the Indiana University insti-tutional review board.

RESULTS

Study Participants

Four hundred forty vehicles and driv-ers were approached and 296 drivdriv-ers participated. Drivers refusing to par-ticipate did so because of time con-straints or convenience, and no addi-tional data were collected. Twenty children in wheelchairs were excluded from this analysis as well as 1 child whose restraint type was unknown. The remaining 275 drivers transported 294 CSHCN and 135 children without special needs. The drivers’ demo-graphic information, vehicle type, as well as the age, gender, weight, rela-tionship, medical diagnoses, and clinic visited for the CSHCN are shown in Ta-bles 2 and 3. The majority of the drivers were white mothers who had at least a high school degree.

CSS Selection

Table 4 shows restraint type by age and weight for the 294 CSHCN whose seat was recorded. All CSS, belt-positioning booster seats (BPB), and specialized medical seats observed were Federal Motor Vehicle Safety Standard (FMVSS) 213 approved.6 Of

the 294 children, 248 (84.4%) were⬍8 years of age and weighedⱕ80 lb, and should be transported in a CSS or booster seat. Of these 248 children, 187 (75.4%) were observed traveling in a standard CSS (111) or booster seat (76). The remaining 61 children were restrained by: a lap belt (4.9%), a lap/ shoulder belt (54.1%), a specialized medical seat (24.6%), an unspecified “other” restraint (8.2%), or were

unre-strained (8.2%). No car beds or travel vests were observed in the study.

Fifteen specialized medical seats were observed securing CSHCN. The medical seats were the Britax Inc Traveler Plus (Britax USA, Charlotte, NC) (9), Snug

Seat Inc Gorilla (3) (Snug Seat Inc, Mathews, CA), the Columbia Therape-dic vehicle restraint system-child (1) (Columbia Medical, Santa Fe Springs, CA), and Columbia Therapedic vehicle restraint system-adult (Columbia Med-ical, Santa Fe Springs, CA) (2). Of the 251 drivers who responded to a query about their awareness of large, spe-cialized medical seats, 112 (44.6%) were aware that these seats were available.

Table 5 shows the results of the logis-tic regression analysis for seat selec-tion and driver variables. For the 294 CSHCN, 241 (82.0%) were in an

appro-n %

Age, y

20–29 67 25.0

30–39 122 45.5

40–49 61 22.8

50–59 16 6.0

ⱖ60 2 0.7

No response 7

Gender

Male 52 19.8

Female 211 80.2

No response 12

Racea

White 233 87.3

Black 26 9.7

Native American 8 3.0

Asian/Pacific Islander 4 1.5

Other 8 3.0

No response 8

Annual household income, $

⬍20 000 59 22.0

20 000–34 999 59 22.0

35 000–49 000 63 23.5

50 000–100 000 70 26.1

⬎100 000 17 6.3

No response 7

Highest level of education attained

High school graduate or less

81 30.5

Some college or bachelor degree

132 49.6

Advanced degree 29 10.9

Trade school or other 24 9.0

No response 9

Vehicle characteristics

Sport utility vehicle 107 39.5

Passenger car 83 30.6

Minivan 51 18.8

Van 18 6.6

Pickup truck 8 3.0

Other 4 1.5

No response 4

Median (range) vehicle year 1999 (1980–2006) Median (range) distance

traveled

40 miles (1–214)

Government

financial/Medicaid participant

No 82 31.1

Yes 182 68.9

No response 11

aSome participants reported1 racial category.

CSHCN Characteristic n %

Age, y

⬍1 22 7.5

1–3 74 25.2

4–7 93 31.6

8–12 75 25.5

13–18 30 10.2

Gender

Male 157 54.5

Female 131 45.5

No response 6

Relationship to driver

Child 256 88.3

Grandchild 22 7.6

Sibling 1 0.3

Related 4 1.4

Unrelated 2 0.7

Foster child 5 1.7

No response 4

Weight, lb

⬍40 123 42.1

40–80 123 42.1

ⱖ81 46 15.8

No response 2

Medical conditionsa

Behavioral/developmental 64 Neurologic/neuromuscular 95 Genetic disorders/chromosomal abnormalities 22 Other 120

Clinic visiteda

Cerebral palsy 43

Spina bifida 9

Pulmonary 33

Developmental 103

Cast clinic 5

Neurology 10

Down syndrome clinic 10

Other clinics 81

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priate restraint system. No signifi-cant driver variables were associ-ated with appropriate CSS selection on either the bivariate or multivariate analyses.

Use/Misuse of CSSs

For the 111 CSHCN observed in a stan-dard CSS, 93.6% were buckled in the CSS. Of those CSHCN buckled into the CSS, the harnesses were at the proper

location for 58.7%, appropriately snug (39.3%), and the retainer chest clips were at the midchest level for 45.0% of those observed. Ninety-two percent of the CSSs were correctly anchored with a seat belt or lower anchor. There were 54 standard CSSs that should have been anchored with top tethers to the vehicle on the basis of the child’s weight and CSS model; only 11(20.3%) used the top tether. There were 28 CSHCN⬍1 year of age or⬍20 lb who should have been rear-facing in the rear seat. Two of these children were observed in the front seat and 3 were forward-facing in the rear seat. Of the 15 large medical seats observed, 6 were tethered appropriately, 2 in-correctly, 2 did not require tethering (because of the child’s weight or seat model); 5 seats that should have been tethered were not. There were 76 CSHCN transported in booster seats, and of these only 42.5% (31/ 73) were observed to be using the seat belt properly. Fourteen of the 76

TABLE 5 Bivariate and Multivariate Odds Ratios From a Logistic Regression Model to Predict Appropriate Seat Selection and Any CSS Misuse

Variable Appropriate Seat Selection At Least 1 CSS Misuse

Bivariate OR Multivariate OR Bivariate OR Multivariate OR

OR 95% CL P OR 95% CL P OR 95% CL P OR 95% CL P

Driver age, y .407 .310 .012 .379

20–29 1 Ref 1 Ref 1 Ref 1 Ref

30–39 0.85 0.38, 1.93 0.85 0.33, 2.15 0.34 0.15, 0.76 0.57 0.23, 1.39

40–49 0.85 0.33, 2.20 0.71 0.24, 2.08 0.24 0.10, 0.59 0.53 0.20, 1.42

ⱖ50 0.37 0.12, 1.21 0.31 0.08, 1.12 0.67 0.16, 2.83 1.35 0.29, 6.22

Driver gender .127 .148 .082 .044

Male 1 Ref 1 Ref 1 Ref 1 Ref

Female 1.76 0.85, 3.61 1.78 0.82, 3.89 0.50 0.23, 1.09 0.43 0.19, 0.98

Race .152 .127 .031 .038

Nonwhite 1 Ref 1 Ref 1 Ref 1 Ref

White 1.84 0.80, 4.24 2.03 0.82, 5.01 0.26 0.08, 0.88 0.26 0.07, 0.93

Household income, $ .178 .212 .016 .255

⬍20 000 1 Ref 1 Ref 1 Ref 1 Ref

20 000–34 999 2.97 1.00, 8.87 2.84 0.92, 8.72 0.32 0.12, 0.90 0.30 0.10, 0.93

35 000–49 999 0.93 0.41, 2.10 1.02 0.42, 2.50 0.28 0.10, 0.75 0.30 0.10, 0.92

50 000–100 000 1.83 0.75, 4.47 2.28 0.77, 6.75 0.21 0.08, 0.56 0.30 0.10, 0.97

⬎100 000 1.14 0.28, 4.62 1.98 0.31, 12.79 0.14 0.04, 0.50 0.27 0.05, 1.43

Education .426 .692 .001 .320

⬍College 1 Ref 1 Ref 1 Ref 1 Ref

ⱖCollege 1.34 0.66, 2.72 1.19 0.50, 2.86 0.39 0.22, 0.70 0.70 0.35, 1.41

Government aid .433 .244 ⬍.001 .102

No 1 Ref 1 Ref 1 Ref 1 Ref

Yes 1.31 0.67, 2.55 1.66 0.71, 3.87 2.94 1.65, 5.24 1.80 0.89, 3.62

OR indicates odds ratio; CL, confidence limit.

TABLE 4 CSS Selection According to Age and Weight

Restraint Device Type CSHCN Demographics (N⫽294)

0 to⬍1 y (0–19 lb) (N⫽28)

1 to 3 y (20–39 lb) (N⫽100)

4 to 7 y (40–80 lb) (N⫽120)

8 to 12 y (N⫽25)

ⱖ13 y (N⫽21)

n % n % n % n % n %

Infant-only seat 21 75.0 1 1.0

Convertible 7 25.0 46 46.0 1 0.8

Integrated seat 1 1.0

Combination with harness 22 22.0 8 6.7

Forward-facing only 4 4.0

Shield booster 1 1.0 1 0.8

High-back BPB 16 16.0 20 16.7 1 4.0

Backless BPB 4 4.0 34 28.3

Lap belt 3 2.5 1 4.0

Lap/shoulder belt 2 2.0 31 25.8 22 88.0 19 90.5

Special needs 1 1.0 14 11.7

None 5 4.2 1 4.0 1 4.8

Lap/shoulder with adjuster 1 4.8

Other 2 2.0 3 2.5

Total 28 100 100 100.0 120 100.0 25 100.0 21 100.0

BPB indicates belt positioning booster seat. Due to rounding some totals may not be exactly 100%.

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years of age or ⬍40 lb. Of the 46 CSHCN who wereⱖ8 years of age, 42 (91.3%) were secured by a lap/shoul-der seat belt, 1 in a high-back booster seat, 1 with a lap belt, and 2 children were unrestrained.

There was sufficient data to determine misuse for 280 CSSs. There was at least 1 misuse observed for 205 (73.2%) of the CSSs. Driver age, house-hold income, education, and govern-mental aid were significantly related to at least 1 misuse in the bivariate but not the multivariate analysis. Only driver race was significant in both analyses. Table 5 shows the results of the logistic regression analysis for any CSS misuse.

Postural Support

The head, neck, and trunk control of the 187 CSHCN in CSSs and booster seats were assessed and 19.4% (35/ 180) could have benefited from a child restraint system offering built-in head/trunk support or additional sup-port (rolled blankets or towels outside of the harness) to assist in positioning.

CSS Modifications

Sixty-one of the 253 drivers (24.1%) re-ported that they modified the standard CSS to better fit their CSHCN. Fifty-nine of them described how they modified the CSS, which included placing pad-ding under the cover of the CSS (20.3%), under the harness (47.5%), or behind the child (30.5%). Frame alter-ation of the CSS was reported by 8.5%, and 32.2% reported nonspecific changes.

Front-Seat Occupant Position

Thirty-six of the 294 children were ob-served in the front passenger seat (22 were⬍13 years of age). For these 36 children, 27 drivers reported moving the child to the front seat to meet med-ical needs. Forty-nine of the 275

driv-ers responded they sometimes trans-ported the CSHCN in the front seat. Forty-seven of the 275 reported moving the passenger seat all the way back, and 22 of 275 reported the passenger-side airbag was deactivated.

Drivers were asked where they re-ceived their information for method of installation and use of the child’s CSS. The 253 drivers who responded learned about the CSS from the side panel decal (53.4%), CSS manual (36.8%), CPST or therapist (9.9%), and doctor (2.8%).

Transported medical equipment was observed in 71 vehicles, and the equip-ment was properly secured in only 6 vehicles. Drivers were asked if they limited travel because of the child’s special needs. Of the 262 respondents, 31.7% indicated that they limited travel, and 30.3% had an additional adult in the vehicle to assist the child. Table 6 is a summary that compares the observed frequency of a caregiv-er’s compliance with AAP guidelines.

DISCUSSION

This is one of the first studies to com-pare guidelines for the transportation of CSHCN with actual practice and to quantify CSHCN occupant protection behavior. Although most drivers se-lected an appropriate CSS, the major-ity of seats had at least 1 misuse. Most drivers used an unmodified CSS with

proper body-positioning in the rear seating position. In those circum-stances when drivers deviated from guidelines, it seems from the survey that the caregiver chose these prac-tices to facilitate care of the child dur-ing transport.

A recent study of children with special physical and behavioral needs trans-ported to an Israeli rehabilitation facil-ity found a high prevalence of restraint nonuse and misuse.2 Compared with

our study, those drivers had cultural, socioeconomic, and educational differ-ences, which may influence knowledge and practice. A survey by Paley et al7in

1993 of restraint use among children with disabilities at cerebral palsy and myelomeningocele clinics demonstrated that 52% of the seats used to transport children to clinics were unsafe. Unsafe criteria included models that did not meet federal safety standards, side-facing in vehicle, structurally modified seats, seats not anchored to the vehicle, or the child was unrestrained. In our study, a large proportion (73.2%) of CSSs had at least 1 observed misuse. Most misuses involved a loose or improperly positioned harness. The proportion of misuse is similar to that reported by De-cina and Lococo8 for all children in 6

states where misuse was 72.6%. In our study, all seats met FMVSS 213,6 none

were side-facing, and few children were unrestrained.

AAP Recommendation Observation Reported No. Observed/

No. Sampled %

Standard CSS and booster seat Choice appropriate 241/294 82.0

Postural support appropriatea Those needing support 35/180 19.4

CSS modificationb Drivers reporting seat modifications 61/194 31.4

Vehicle seating position Front seating position 36/294 12.2

Medical equipment secured Properly secured 6/71 8.5

Limited travelc Reported limited travel 83/262 31.7

Had another adult in vehiclec Reported another adult assisted in

transport

79/262 30.3

aSeven CSHCN did not have postural support needs recorded.

bEighty-one drivers did not respond to this question.

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Most drivers reported that they re-ceived their CSS information from the seat manufacturer and much fewer from CPSTs, therapists, or doctors. In our institution, educational material on the transportation of CSHCN is lo-cated throughout the outpatient clinic building, and occupational therapists with specialized training on the cor-rect use of occupant restraints are available for consultation. This study revealed that drivers who were younger, nonwhite, had a lower in-come and educational level, and re-ceived government aid were more likely to have a misuse and could ben-efit from more intense interventions.

CSS Selection

The AAP recommends that standard/ conventional CSSs be used when pos-sible to transport CSHCN, because a standard CSS will often meet the child’s occupant restraint needs with-out the added expense of a specialized medical seat. A medical CSS for CSHCN should be used when the child’s weight or height exceeds the limits of a stan-dard CSS or the child has unique posi-tioning needs.3In our study, most

driv-ers chose the appropriate CSS.

All children, including CSHCN, should remain rear-facing to the highest weight and height limits allowed by the CSS manufacturer. Rear-facing is es-pecially important for children with low muscle tone, poor head control, or airway obstruction who could benefit from being in a rear-facing orientation to much higher ages, weights, and lengths.

Our study observed that 16.5% of CSHCN were inappropriately secured by a lap belt, lap/shoulder belt, or by being unrestrained. Also observed were a number of children trans-ported in a booster seat who because of their age or weight would have a CSS with a 5-point harness recommended. As part of routine anticipatory

guid-ance, primary care providers should ask the parent/caregiver about trans-porting practices. As a child ap-proaches a weight, height, or age that may warrant a change in the CSS, pri-mary care providers have an opportu-nity to counsel families about appro-priate restraint selection. Even when the seat selection was appropriate, our study observed a high misuse rate. Primary care providers should be-come familiar with CPSTs (especially those with CSHCN experience) in their community and use these resources to assist parents in the appropriate choice and correct use of CSSs.

Postural Support

Placing rolled blankets, towels, or foam rolls outside of the harness path is recommended to provide lateral support and prevent slumping for chil-dren with low trunk or neck tone.3

Al-most 20% of the children observed would have benefited from the use of postural support. Specialized medical seats or standard CSSs with rolled blankets, towels, or foam rolls may provide needed support for children with poor trunk and neck control.

CSS Modifications

The 1999 AAP guidelines recommend no CSS modification, because this may alter the restraint protection during a crash.3 Changes to the padding,

har-ness, or shell of the CSS may alter the energy transfer to the child during a crash resulting in an increased risk of injury. An alternative to address fit or postural support issues may be a spe-cialized medical seat fitted by a CPST who has training in transportation is-sues for CSHCN.

Front-Seat Occupant Position

It is recommended that all children

⬍13 years of age travel in the rear seating position.9 However, drivers

may choose to transport CSHCN in the front seating position to address

situ-ations requiring immediate attention. In our study, 8.1% of CSHCN were ob-served transported inappropriately in the front seat. By comparison, Korn et al2 observed that 11% of CSHCN who

arrived at a Jerusalem rehabilitation facility were seated in the front. In the National Highway Traffic Safety Admin-istration (NHTSA) 2004 survey of child occupant protection practice, 9.4% of all children weighing⬍80 lb were re-strained in the front seating position.10

During 2006,⬎10% of all Indiana child occupants ⬍8 years of age were ob-served in the front seat.11Our drivers

reported moving the CSHCN to the front seating position for easier ac-cess. Most drivers pushed the front passenger seat back but few deacti-vated the passenger-side airbag. CSHCN are frequently smaller in stat-ure than typical children of similar age. Small children are susceptible to serious injury and death from deploy-ment of airbags, and CSHCN may be more vulnerable because of hypotonia, anatomic abnormalities, medical de-vices, or appliances. If CSHCN must be transported in the front seating posi-tion, the driver should be aware of the risk of airbag-related injuries and move the seat to the rear-most posi-tion. If possible, the passenger-side airbag should be deactivated. Although advice from the NHTSA9 and

regula-tions in some states allow children ⱖ13 years of age to ride in the front seat, CSHCN who are smaller and have poor muscle tone and strength may be safer in the rear seat position regard-less of age.3

Medical Equipment

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potential danger to all the vehicle oc-cupants. Unfortunately, there are lim-ited additional options for securing medical equipment safely. Develop-ment of restraining devices for medi-cal equipment is needed.

Travel

Falkmer and Gregersen12 described

driver anxiety about issues associated with the transportation of children with disabilities. These included pos-tural support and difficulties placing a child in or removing from a vehicle. Our drivers expressed similar con-cerns, and approximately one third of the respondents limited travel be-cause of transporting challenges. A similar proportion had another adult in the vehicle to assist the child. The AAP recommends that, when possible, an adult should ride in the back seat next to the child to provide care if needed.3

Limitations

This pilot study was based on a con-venience sample of drivers at a ter-tiary children’s medical center and may not be generalizable to all driv-ers who transport CSHCN. The popu-lation of drivers in our study was predominately women, white, and

the Indiana or US general popula-tion.13Some data were based on

self-reports and may be biased. We only obtained data on the child’s age and weight. However, we did observe some CSHCN incorrectly transported in a booster seat, but because height was not recorded, those children whose height exceeded the recom-mendations for a CSS could not be identified. Also, the driver may have received input from another adult in the vehicle, which would not reflect the driver’s knowledge or attitudes. Because the study was conducted during clinic hours, it is possible that the driver for this visit was not the primary person responsible for transporting the child. It is also un-clear if there is a difference between caregivers/drivers who receive treatment for their CSHCN at a ter-tiary children’s hospital or a commu-nity hospital. These differences could reflect problems with access to knowledge or equipment and influ-ence the ability to generalize our re-sults. Individual CSHCN diagnoses were too few to determine relation-ships between them and CSS use. The AAP guidelines were written for the primary care provider, and

par-CONCLUSIONS

This is one of the first studies to com-pare the guidelines for transporting CSHCN to actual practice. Although most families chose the appropriate seat, there was a high misuse rate. Drivers deviated from recommenda-tions to facilitate care of the child dur-ing transport. It is important to under-stand how recommended practice compares with how families actually transport CSHCN. By identifying gaps between the guidelines and practice, barriers to proper use and subse-quent solutions can be identified. Dis-cussions about the proper transpor-tation of CSHCN and referrals to a CPST with special training for CSHCN may improve safety, care, and com-fort in the vehicle. A review of guide-lines for the safe transportation of CSHCN for the primary care provider was recently published.14Additional

information on the safe transporta-tion of CSHCN and contact informa-tion for individuals with special training in the transportation needs of CSHCN may be obtained from the National Center for the Safe Transporta-tion of CSHCN (www.preventinjury.org, 800-543-6227; www.NHTSA.dot.gov, or www.safekids.org).

REFERENCES

1. Wegner MV, Girasek DC. How readable are child safety seat instructions?Pediatrics.2003;111(3): 588 –591

2. Korn T, Katz-Leurer M, Meyer S, Gofin R. How children with special needs travel with their parents: observed versus reported use of vehicle restraints.Pediatrics.2007;119(3). Available at: www.pediatrics.org/cgi/content/full/119/3/e637

3. Bull M, Agran P, Laraque D, et al; American Academy of Pediatrics, Committee on Injury and Poison Prevention. Transporting children with special health care needs.Pediatrics.1999;104(4 pt 1): 988 –992

4. American Academy of Pediatrics. AAP children’s health topics: parenting corner Q&A: transport-ing children with special needs. Available at: www.aap.org/publiced/BR㛭SpNeedsCarSeats.htm. Accessed September 3, 2007

5. Decina LE, Lococo KH, Block AW. Misuse of child restraints: results of a workshop to review field data results. NHTSA DOT HS 809 851. Available at: www.nhtsa.dot.gov/people/injury/research/ TSF㛭MisuseChildRetraints/809851.html. Accessed September 16, 2008

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Printing Office, Washington, 2008, Part 571.213. Available at: www.nhtsa.dot.gov/portal/site/ nhtsa/menuitem.258ac646ab16428891e67a1090008a0c/. Accessed June 12, 2009

7. Paley K, Walker JL, Cromwell F, Enlow C. Transportation of children with special seating needs. South Med J.1993;86(12):1339 –1341

8. Decina LE, Lococo KH. Child restraint systems use and misuse in six states.Accid Anal Prev. 2005;37(3):583–590

9. National Highway Traffic Safety Administration. Transportation safety tips for children. Traveling safely with children: the basics. December 2004. DOT HS808 301. Available at: www.nhtsa.dot.gov/ people/injury/childps/newtips/index.htm. Accessed February 2, 2008

10. Decina LE, Lococo KH; National Highway Traffic Safety Administration. Transportation: misuse of child restraints. January 2004. DOT HS 809 671. Available at: www.nhtsa.dot.gov/people/injury/ research/Misuse/index.html. Accessed March 15, 2008

11. Sapp D, Thelin R; Center for Urban Policy and the Environment. Indiana Child Restraint Survey: 2001–2006. Available at: www.preventinjury.org/uploads/researchinfo/ResearchInfo㛭10.pdf. Ac-cessed June 10, 2008

12. Falkmer T. Gregersen NP. Perceived risk among parents concerning the travel situation for children with disabilities.Accid Anal Prev.2002;34(4):553–562

13. US Census Bureau. State and county quickfacts. Available at: http://quickfacts.census.gov/qfd/ states/18000.html. Accessed March 9, 2008

14. Bull MJ. Safe transportation of children with special health care needs: guidelines for the primary care provider.Pediatr Ann.2008;37(9):624 – 631

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DOI: 10.1542/peds.2008-1124 originally published online July 13, 2009;

2009;124;596

Pediatrics

Joseph O'Neil, Janell Yonkman, Judith Talty and Marilyn J. Bull

Services

Updated Information &

http://pediatrics.aappublications.org/content/124/2/596

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/124/2/596#BIBL

This article cites 6 articles, 2 of which you can access for free at:

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Carseat Safety

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Injury, Violence & Poison Prevention

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DOI: 10.1542/peds.2008-1124 originally published online July 13, 2009;

2009;124;596

Pediatrics

Joseph O'Neil, Janell Yonkman, Judith Talty and Marilyn J. Bull

Recommendations and Practice

Transporting Children With Special Health Care Needs: Comparing

http://pediatrics.aappublications.org/content/124/2/596

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 1 Recommendations for Transportation of CSHCN in Motor Vehicles
TABLE 2 Driver and Vehicle Characteristics(N � 275)
TABLE 4 CSS Selection According to Age and Weight
TABLE 6 CSS Restraint Use Recommendations Compared With the Observed Practice of DriversTransporting CSHCN

References

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