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Screening for cardiopulmonary events in neonates: a review of the infant car seat challenge

Journal of Perinatology volume 35, pages 235–240 (2015)Cite this article

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Abstract

The infant car seat challenge (ICSC), or period of observation in a car safety seat before discharge to monitor for episodes of apnea, bradycardia and desaturation, is one of the most common tests performed on preterm neonates in the United States. However, the utility of the ICSC to identify infants at risk for adverse cardiopulmonary events in the car seat remains unclear. Minimal evidence exists to guide clinicians in performance of this test including appropriate inclusion criteria and failure criteria. In this article, the origins of the ICSC are discussed as well as potential etiologies of desaturations and bradycardia in the car seat position. Current literature on implementation, inclusion and failure criteria, incidence of failure and data on the meaning of a ‘passed’ vs ‘failed’ ICSC are discussed. Emphasis is made on minimizing time in car seats and seated devices given concern over the risk of desaturations.

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References

  1. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2010 Data. 2012 US Department of Transportation, Washington DC.

  2. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Auto safety for the infant and young child. Am Acad Pediatr News Comment 1974; 10: 11.

    Google Scholar 

  3. Bull MJ, Stroup KB . Premature infants in car seats. Pediatrics 1985; 75 (2): 336–339.

    CAS  PubMed  Google Scholar 

  4. Willett LD, Leuschen MP, Nelson LS, Nelson RM Jr . Risk of hypoventilation in premature infants in car seats. J Pediatr 1986; 109 (2): 245–248.

    Article  CAS  PubMed  Google Scholar 

  5. Willett LD, Leuschen MP, Nelson LS, Nelson RM Jr . Ventilatory changes in convalescent infants positioned in car seats. J Pediatr 1989; 115 (3): 451–455.

    Article  CAS  PubMed  Google Scholar 

  6. American Academy of Pediatrics Committee on Injury and Poison Prevention and Committee on Fetus and Newborn. Safe transportation of premature infants. Pediatrics 1991; 87 (1): 120–122.

  7. American Academy of Pediatrics Committee on Injury and Poison Prevention and Committee on Fetus and Newborn. Safe transportation of premature and low birth weight infants. Pediatrics 1996; 97 (5): 758–760.

  8. Bull M, Agran P, Laraque D, Pollack SH, Smith GA, Spivak HR et al. American academy of pediatrics. committee on injury and poison prevention. Safe transportation of newborns at hospital discharge. Pediatrics 1999; 104 (4, Part 1): 986–987.

    Article  CAS  PubMed  Google Scholar 

  9. Bull MJ, Engle WA, Committee on Injury, Violence, and Poison Prevention and Committee on Fetus and Newborn, American Academy of Pediatrics. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics 2009; 123: 1424–1429.

    Article  PubMed  Google Scholar 

  10. Hamilton B, Martin J, Ventura S . Births: prelimary data for 2011. Natl Vital Stat Rep 2012; 61: 1–20.

    PubMed  Google Scholar 

  11. Lincoln M . Car seat safety: literature review. Neonatal Netw 2005; 24: 29–31.

    Article  PubMed  Google Scholar 

  12. Pilley E, McGuire W . Pre-discharge ‘car seat challenge’ for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2006; 1: CD005386.

    Google Scholar 

  13. Callahan CW, Sisler C . Use of seating devices in infants too young to sit. Arch Pediatr Adolesc Med 1997; 151 (3): 233–235.

    Article  CAS  PubMed  Google Scholar 

  14. Carlo WA, Beoglos A, Siner BS, Martin RJ . Neck and body position effects on pulmonary mechanics in infants. Pediatrics 1989; 84 (4): 670–674.

    CAS  PubMed  Google Scholar 

  15. Tonkin SL, McIntosh CG, Hadden W, Dakin C, Rowley S, Gunn AJ . Simple car seat insert to prevent upper airway narrowing in preterm infants: a pilot study. Pediatrics 2003; 112 (4): 907–913.

    Article  PubMed  Google Scholar 

  16. McIntosh CG, Tonkin SL, Gunn AJ . Randomized controlled trial of a car safety seat insert to reduce hypoxia in term infants. Pediatrics 2013; 132: 326–331.

    Article  PubMed  Google Scholar 

  17. Dollberg S, Yacov G, Mimouni F, Ashbel G . Effect of head support on oxygen saturation in preterm infants restrained in a car seat. Am J Perinatol 2002; 19: 115–118.

    Article  PubMed  Google Scholar 

  18. Hertz G, Aggarwal R, Rosenfeld WN, Greensher J . Premature infants in car seats: effect of sleep state on breathing. J Sleep Res 1994; 3: 186–190.

    Article  CAS  PubMed  Google Scholar 

  19. Engelberts AC, de Jonge GA . Choice of sleeping position for infants: possible association with cot death. Arch Dis Child 1990; 65: 462–467.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG . Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med 1993; 329: 377–382.

    Article  CAS  PubMed  Google Scholar 

  21. Guntheroth WG, Spiers PS . Sleeping prone and the risk of sudden infant death syndrome. JAMA 1992; 267: 2359–2362.

    Article  CAS  PubMed  Google Scholar 

  22. Fyfe KL, Yiallourou SR, Wong FY, Odoi A, Walker AM, Horne RS . Cerebral oxygenation in preterm infants. Pediatrics 2014; 134: 435–445.

    Article  PubMed  Google Scholar 

  23. Williams LE, Martin JE . Car seat challenges: Where are we in implementation of these programs? J Perinat Neonatal Nurs 2003; 17: 158–163.

    Article  PubMed  Google Scholar 

  24. Salhab WA, Khattak A, Tyson JE, Crandell S, Sumner J, Goodman B et al. Car seat or car bed for very low birth weight infants at discharge home. J Pediatr 2007; 150: 224–228.

    Article  PubMed  Google Scholar 

  25. Davis NL, Zenchenko Y, Lever A, Rhein L . Car seat safety for preterm neonates: implementation and testing parameters of the infant car seat challenge. Acad Pediatr 2013; 13: 272–277.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Bass JL . The infant car seat challenge: determining and managing an ‘abnormal’ result. Pediatrics 2010; 125: 597–598.

    Article  PubMed  Google Scholar 

  27. Ojadi VC, Petrova A, Mehta R, Hegyi T . Risk of cardio-respiratory abnormalities in preterm infants placed in car seats: a cross-sectional study. BMC Pediatr 2005; 5: 28.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Schutzman DL, Salvador A, Janeczko M, Weisberg L, Tran N, Porat R . A comparison of the infant car seat challenge and the polysomnogram at the time of hospital discharge. Arch Dis Child Fetal Neonatal Ed 2013; 98: F411–F415.

    Article  PubMed  Google Scholar 

  29. Elder DE, Russell L, Sheppard D, Purdie GL, Campbell AJ . Car seat test for preterm infants: comparison with polysomnography. Arch Dis Child Fetal Neonatal Ed 2007; 92: F468–F472.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Merchant JR, Worwa C, Porter S, Coleman JM, deRegnier RA . Respiratory instability of term and near-term healthy newborn infants in car safety seats. Pediatrics 2001; 108: 647–652.

    Article  CAS  PubMed  Google Scholar 

  31. Davis NL, Gregory ML, Rhein L . Test–retest reliability of the infant car-seat challenge. J Perinatol 2014; 34: 54–58.

    Article  CAS  PubMed  Google Scholar 

  32. Young B, Shapira S, Finer N . Predischarge car seat safety study for premature infants. Paediatr Child Health 1996; 1: 202–205.

    Article  Google Scholar 

  33. Degrazia M, Guo CY, Wilkinson AA, Rhein L . Weight and age as predictors for passing the infant car seat challenge. Pediatrics 2010; 125: 526–531.

    Article  PubMed  Google Scholar 

  34. Poets CF, Stebbens VA, Alexander JR, Arrowsmith WA, Salfield SA, Southall DP . Oxygen saturation and breathing patterns in infancy. 2: Preterm infants at discharge from special care. Arch Dis Child 1991; 66: 574–578.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Stebbens VA, Poets CF, Alexander JR, Arrowsmith WA, Southall DP . Oxygen saturation and breathing patterns in infancy. 1: Full term infants in the second month of life. Arch Dis Child 1991; 66: 569–573.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Poets CF, Stebbens VA, Alexander JR, Arrowsmith WA, Salfield SA, Southall DP . Arterial oxygen saturation in preterm infants at discharge from the hospital and six weeks later. J Pediatr 1992; 120: 447–454.

    Article  CAS  PubMed  Google Scholar 

  37. Hunt CE, Corwin MJ, Weese-Mayer DE, Ward SL, Ramanathan R, Lister G et al. Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life. J Pediatr 2011; 159: 377–383.e1.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Moyer-Mileur LJ, Nielson DW, Pfeffer KD, Witte MK, Chapman DL . Eliminating sleep-associated hypoxemia improves growth in infants with bronchopulmonary dysplasia. Pediatrics 1996; 98 (4 Pt 1): 779–783.

    CAS  PubMed  Google Scholar 

  39. Richard D, Poets CF, Neale S, Stebbens VA, Alexander JR, Southall DP . Arterial oxygen saturation in preterm neonates without respiratory failure. J Pediatr 1993; 123: 963–968.

    Article  CAS  PubMed  Google Scholar 

  40. Samuels MP, Poets CF, Southall DP . Abnormal hypoxemia after life-threatening events in infants born before term. J Pediatr 1994; 125: 441–446.

    Article  CAS  PubMed  Google Scholar 

  41. Hunt CE, Corwin MJ, Baird T, Tinsley LR, Palmer P, Ramanathan R et al. Cardiorespiratory events detected by home memory monitoring and one-year neurodevelopmental outcome. J Pediatr 2004; 145: 465–471.

    Article  PubMed  Google Scholar 

  42. Bass JL, Corwin M, Gozal D, Moore C, Nishida H, Parker S et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics 2004; 114: 805–816.

    Article  PubMed  Google Scholar 

  43. Vagedes J, Poets CF, Dietz K . Averaging time, desaturation level, duration and extent. Arch Dis Child Fetal Neonatal Ed 2013; 98: F265–F266.

    Article  PubMed  Google Scholar 

  44. Ahmed SJ, Rich W, Finer NN . The effect of averaging time on oximetry values in the premature infant. Pediatrics 2010; 125: e115–e121.

    Article  PubMed  Google Scholar 

  45. Martin RJ, Wang K, Koroglu O, Di Fiore J, Kc P . Intermittent hypoxic episodes in preterm infants: do they matter? Neonatology 2011; 100: 303–310.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Martin RJ, Di Fiore JM, Macfarlane PM, Wilson CG . Physiologic basis for intermittent hypoxic episodes in preterm infants. Adv Exp Med Biol 2012; 758: 351–358.

    Article  CAS  PubMed  Google Scholar 

  47. Canadian Paediatric Society. Assessment of babies for car seat safety before hospital discharge. Paediatr Child Health 2000; 5: 53–63.

  48. Simsic JM, Masterson K, Kogon BE, Kirshbom PM, Kanter KR . Pre-hospital discharge car safety seat testing in infants following congenital heart surgery. Pediatr Cardiol 2008; 29: 313–316.

    Article  CAS  PubMed  Google Scholar 

  49. Bass JL, Mehta KA . Oxygen desaturation of selected term infants in car seats. Pediatrics 1995; 96 (2 Pt 1): 288–290.

    CAS  PubMed  Google Scholar 

  50. Davis NL, Condon F, Rhein LM . Epidemiology and predictors of failure of the infant car seat challenge. Pediatrics 2013; 131: 951–957.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Kornhauser Cerar L, Scirica CV, Stucin Gantar I, Osredkar D, Neubauer D, Kinane TB . A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds. Pediatrics 2009; 124: e396–e402.

    Article  PubMed  Google Scholar 

  52. Nagase H, Yonetani M, Uetani Y, Nakamura H . Effects of child seats on the cardiorespiratory function of newborns. Pediatr Int 2002; 44 (1): 60–63.

    Article  PubMed  Google Scholar 

  53. Kinane TB, Murphy J, Bass JL, Corwin MJ . Comparison of respiratory physiologic features when infants are placed in car safety seats or car beds. Pediatrics 2006; 118: 522–527.

    Article  PubMed  Google Scholar 

  54. DeGrazia M . Stability of the infant car seat challenge and risk factors for oxygen desaturation events. J Obstet Gynecol Neonatal Nurs 2007; 36: 300–307.

    Article  PubMed  Google Scholar 

  55. Tonkin SL, Vogel SA, Bennet L, Gunn AJ . Apparently life threatening events in infant car safety seats. BMJ 2006; 333: 1205–1206.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Cote A, Bairam A, Deschenes M, Hatzakis G . Sudden infant deaths in sitting devices. Arch Dis Child 2008; 93: 384–389.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The author thanks Jennifer Thompson in the Division of Neonatology, as well as Katherine Downton, Research/Education/Outreach Librarian, from the University of Maryland, Baltimore, MD, Health Sciences and Human Services Library for their assistance. I also thank Larry Rhein and John Zupancic for their ongoing mentorship and dedication. No external funding was secured for this study.

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  1. Department of Pediatrics, Division of Neonatology, University of Maryland Children’s Hospital, University of Maryland School of Medicine, Baltimore, MD, USA

    N L Davis

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Correspondence to N L Davis.

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NLD has no financial relationships relevant to this article to disclose.

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Davis, N. Screening for cardiopulmonary events in neonates: a review of the infant car seat challenge. J Perinatol 35, 235–240 (2015). https://doi.org/10.1038/jp.2015.1

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