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The Challenge of Positional Car Seat Testing in Healthy Near-term Neonates
The Challenge of Positional Car Seat Testing in Healthy Near-term Neonates Laurie A. Tedeschi, RN
The American Academy of Pediatrics Committee on Injury and Poison Prevention recommends that hospitals develop policies that include a period of observation for any infant less than 37 weeks' gestation in an infant car safety seat before hospital discharge to monitor for apnea, bradycardia, or oxygen desaturation. Development of policy guidelines presents a challenge to health care providers on many levels. What evidence is the basis for this recommendation of the American Academy of Pediatrics? Does this recommendation include healthy near-term infants in level I nurseries? How should such policies be produced and implemented? What training and education will be necessary? How much will this cost? This article reviews the evidence for clinical practice and shares clinical experiences in policy development, education, and cost containment. © 2007 Elsevier Inc. All rights reserved. Keywords: Apnea; Bradycardia; Infant car seats; Oxygen desaturation; Premature infants
The American Academy of Pediatrics (AAP) recommends that discharge policies for newborns include a period of observation in a car safety seat for any infant born at less than 37 weeks' gestation. During this period of observation, the preterm infant should be monitored for apnea, bradycardia, and oxygen desaturation. Policy development is recommended; however, specific guidelines are left to the collaboration of medical and nursing staff to accomplish.1 A review of the clinical evidence is required before undertaking the task of policy development.
Clinical Evidence Willett et al2 compared the frequency of apnea, bradycardia, and oxygen desaturation in preterm infants positioned upright in an infant car seat with those of preterm infants in a prone position. The published findings demonstrated that 30% to 60% of premature infants convalescing from the neonatal intensive care unit experienced more frequent episodes of oxygen desaturation. Preterm infants with a previous history of apnea and bradycardia were more likely to
From the Good Samaritan Hospital, Cincinnati, OH. Address correspondences to Laurie A. Tedeschi, RN, 1075 Stormy Way, Cincinnati, OH 45230. © 2007 Elsevier Inc. All rights reserved. 1527-3369/07/0702-0187$10.00/0 doi:10.1053/j.nainr.2007.03.001
experience apnea and bradycardia as well. This did not occur in randomly selected term infants. Subsequent studies supported these findings.3 Neonatal intensive care units began to implement periods of observation with infants positioned upright in car seats before discharge to monitor episodes of apnea, bradycardia, and oxygen desaturation. Infants born between 34 0/7 to 36 6/7 weeks' gestation are considered near-term/late preterm. Healthy near-term infants admitted to level I newborn nurseries were seldom considered for observation in infant car seats because the risk for adverse cardiorespiratory events was undocumented. Merchant et al4 published a study of 50 term and near-term infants recruited from a level I nursery and monitored for apnea, bradycardia, and oxygen saturation while positioned in infant car seats. The results revealed that 12% of the near-term infants experienced apneic or bradycardic episodes in their car seats, and mean oxygen saturation values declined in the term and near-term infants. Conclusions supported the AAP recommendation of all infants less than 37 weeks' gestation receiving an observation period in an infant car seat, including near-term infants with no specialized nursery care needs. Evidence-based practice integrates critical appraisal of relevant evidence with clinical experience, expertise, and patient preferences and values.5 The Cochrane Database of Systematic Reviews provides resources to assess evidence from randomized controlled clinical trials. In 2005 a systematic review concludes:
“There is no evidence that undertaking a predischarge ‘car seat challenge’ benefits preterm infants. The ‘car seat challenge’ assesses whether preterm infants who are ready for discharge home are prone to episodes of apnoea (stopping breathing), bradycardia (slow heart rate), or desaturation (low oxygen levels) when seated in their car seat. However, it is not clear whether the level of oxygen desaturation, apnoea, or bradycardia detected in the car seat challenge is actually harmful for preterm infants. Additionally, there is concern that use of the car seat challenge may cause undue parental anxiety about the safety of transporting their infant in a car seat. Despite these uncertainties, and despite the widespread use of the test, we have not identified any randomized controlled trials that assessed whether undertaking a car seat challenge is beneficial or harmful to preterm infants.6”
Clinical Experience If the clinical evidence to support practice is imprecise, then what does clinical experience and expertise reveal? Wide variations exist in the evaluation and interpretation of cardiorespiratory stability of healthy near-term infants in infant car seats. In addition, there is inconsistency in recommendations for clinical response to infants who experience physiologic variations in breathing, heart rate, and oxygen saturation. Common clinical practice includes following the AAP guidelines advising that infants experiencing apnea for more than 20 seconds, bradycardia of less than 80 beats per minute, or oxygen saturations below 90% to not travel in the infant car seat. More disparity exists in identifying a course of action for infants who fail to meet the AAP guidelines for cardiorespiratory stability. Some clinicians choose to delay hospital discharge and retest infants at a later date, which is time consuming and expensive. Others elect to transport the infant supine or prone in car bed devices that have recently been designed to withstand collisions but are limited by cost and availability.7 Another alternative is to support posture with blanket rolls or inserts and position the infant car seat at 30 degrees rather than 45 degrees to reduce slouching, which may impact the safety of the restraint system. A pilot study published in 2003 supports the conclusion that episodes of desaturation in infant car seats can be reduced substantially by the use of a simple foam insert that allows the infant to maintain neutral head position.8 Some clinicians report giving infants a respiratory stimulant such as theophylline.9 The AAP recommends the use of a car bed for infants experiencing apnea, bradycardia, or oxygen desaturation during the car seat observation.10 A recently published study of 151 infants weighing less than 1500 grams at birth found no evidence that an event is less likely in a car bed than in a car seat and recommends that whichever device is
used, very low-birth-weight infants require observation during travel.11 Clinical practice diversity exists regarding the length of observation for apnea, bradycardia, and oxygen desaturation in an infant car seat. Timeframes vary from 30 to 90 minutes, with some institutions selecting the timeframe based on the length of the car trip home from the hospital. The practice of individualizing the length of observation is limited by practicality and cost. Neonatal nursing policies published by the National Association of Neonatal Nurses suggest observation of infants in the car seat for 90 minutes.12
Education and Training Implementation of monitoring near-term infants in level I nurseries for a period of observation in infant car seats requires the development of an extensive education and training program for nursing staff and occupies a substantial amount of nursing time in carrying out the observations and educating parents. Because positional car seat testing requires assessment and evaluation, delegation is inappropriate, and the focus of the training and education is the licensed professional nurse. Level I units affiliated with level II or III nurseries may avail themselves of the clinical expertise in those units to develop and implement positional car seat testing policies, training, and education programs. Planning should include hands-on training for nurses in the level I newborn nursery who frequently lack experience initiating and interpreting cardiac, respiratory, and oxygen saturation monitors. Nurses require education and training related to positioning infants in the car seats for testing as well. In addition, documentation of testing data, reporting of results, and parental education should be emphasized during training (Fig 1). An education program for parents and caregivers is essential and should incorporate provisions for parental notification before infant car seat testing (Fig 2) as well as a definition of the responsibilities of the parents and caregivers. The AAP maintains that parents are responsible for the installation of a specific car seat in a specific car, but generic information on the proper use of infant car seats should be provided. Parents should understand that it is the infant's tolerance of positioning in the infant car seat being tested, not the safety of the car seat. Resources and materials used for parent education should undergo periodic review in consultation with healthcare personnel specifically trained by the National Highway Traffic Safety Administration in a 4-day course.1 Specific guidelines for car seat test follow-up include provision of information to the parents. This information encompasses much more than simply reporting the results of the test to the parents or caregivers. Discussion with the parents and caregivers necessitates imparting basic safety information and a clear explanation of the results of the positional car seat testing using terminology they can understand.10 It is important that parents and caregivers recognize that the infant should never be transported in their arms as an alternative to the car seat. Written information supplements education and augments comprehension (Fig 3).
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Fig 1. Sample flowsheet and policy guidelines for positional car seat testing. The AAP does not stipulate how long positioning restrictions should remain in effect, so parents and caregivers need further instructions to follow-up with a pediatrician or clinic regarding discontinuing positioning precautions.10 Some institutions coordinate appointments before discharge in order to facilitate appropriate follow-up (Fig 3).
Key educational points for follow-up care of infants experiencing apnea, bradycardia, or oxygen desaturation during observation in an infant car seat include the following: • Limiting travel time in the car • Transporting the infant in a car bed • Avoiding the use of swings, infant seats, slings, or any devices where the infant is positioned upright or semi-upright • Direct observation of the infant when positioned upright or semi-upright
102
NEWBORN
Financial Concerns A number of costs occur related to the implementation of car seat testing for the near-term infants in a level I nursery. Some equipment such as cardiorespiratory monitors, oximeters, and loaner car beds necessary for the program need to be procured. Licensed professionals require training and educational inservices. Additional nursing hours are required to assess and evaluate all infants less than 37 weeks' gestation for an observation period in an infant car seat. Equipment costs may be reduced if charitable foundations or grants support the purchase of car beds for loaner programs. Monitors from affiliated level II or level III nurseries undergoing equipment upgrades may be available at low or no cost. Expert nursing staff from regional level II and III nurseries are frequently willing to assist with education and training, allowing the use of a “train-the-trainer” model to increase training efficiency and contain costs. Budgeted nursing hours are still likely to increase in order to support the program.
Conclusion A number of clinical concerns surround the implementation of positional car seat testing in healthy near-term infants.
& INFANT NURSING REVIEWS
Fig 1. (continued) A systematic search and critical appraisal of the clinical evidence and expertise provides some direction during this process. Sharing clinical experiences and continuing to examine the results of related clinical research allows refinement of policies, procedures, and educational programs supporting positional car seat testing of healthy near-term infants.
References 1. American Academy of Pediatrics. Committee on Injury and Poison Prevention: safe transportation of newborns at hospital discharge. Pediatrics. 1999;104:986-987.
2. Willett LD, Leuschen P, Nelson LS, et al. Risk of hypoventilation in premature infants in car seats. Pediatrics. 1986;109:245-248. 3. Bass JL, Kishor AM, Camara J. Monitoring premature infants in car seats: implementing the American Academy of Pediatrics policy in a community hospital. Pediatrics. 1993;91:1137-1141. 4. Merchant JR, Worwa C, Porter S, et al. Respiratory instability of term and near-term healthy newborn infants in car safety seats. Pediatrics. 2001;108:647-652. 5. Sackett DL, Straus SE, Richardson WS, et al. Evidencebased Medicine: how to practice and DBM teach. London: Churchill Livingstone; 2000.
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Fig 2. Sample parent letter for use prior to positional car seat test.
Fig 3. Sample parent letter to follow positional car seat test. 104
NEWBORN
& INFANT NURSING REVIEWS
6. Piley E, McGuire W. Pre-discharge “car seat challenge” for preventing morbidity and mortality in preterm infants The Cochrane Database of Systematic Reviews 2005; Retrieved October 19, 2006 from the Cochrane Library web site. www.http://gateway.ut.ovid.com/gw1/ovidweb. cgi. 7. Howard-Salsman KD. Car seat safety for high-risk infants. Neonatal Netw. 2006;25:117-129. 8. Tonkin SL, McIntosh CG, Hadden W, et al. Simple car seat insert to prevent upper airway narrowing in preterm infants: a pilot study. Pediatrics. 2003;112: 907-913.
9. Williams LE, Martin JE. Car seat challenges: where are we in implementation of these programs? J Perinat Neonatal Nurs. 2003;17:158-163. 10. Creehan PA. Sending baby home safely: developing an infant car seat testing program. AWHONN Lifelines. 2002;5:60-70. 11. Salhab WA, Khattak A, Tyson JE, et al. Car seat or car bed for very low birth weight babies at discharge home. Pediatrics. 2007;150:224-228. 12. Altimier L, Brown B, Tedeschi L. NANN guidelines for neonatal policies, procedures, competencies, and clinical pathways. 4th ed. Glenview (Ill): National Association of Neonatal Nurses; 2006.
VOLUME 7, NUMBER 2, JUNE 2007
105
The American Academy of Pediatrics Committee on Injury and Poison Prevention recommends that hospitals develop policies that include a period of observation for any infant less than 37 weeks' gestation in an infant car safety seat before hospital discharge to monitor for apnea, bradycardia, or oxygen desaturation. Development of policy guidelines presents a challenge to health care providers on many levels. What evidence is the basis for this recommendation of the American Academy of Pediatrics? Does this recommendation include healthy near-term infants in level I nurseries? How should such policies be produced and implemented? What training and education will be necessary? How much will this cost? This article reviews the evidence for clinical practice and shares clinical experiences in policy development, education, and cost containment. © 2007 Elsevier Inc. All rights reserved. Keywords: Apnea; Bradycardia; Infant car seats; Oxygen desaturation; Premature infants
The American Academy of Pediatrics (AAP) recommends that discharge policies for newborns include a period of observation in a car safety seat for any infant born at less than 37 weeks' gestation. During this period of observation, the preterm infant should be monitored for apnea, bradycardia, and oxygen desaturation. Policy development is recommended; however, specific guidelines are left to the collaboration of medical and nursing staff to accomplish.1 A review of the clinical evidence is required before undertaking the task of policy development.
Clinical Evidence Willett et al2 compared the frequency of apnea, bradycardia, and oxygen desaturation in preterm infants positioned upright in an infant car seat with those of preterm infants in a prone position. The published findings demonstrated that 30% to 60% of premature infants convalescing from the neonatal intensive care unit experienced more frequent episodes of oxygen desaturation. Preterm infants with a previous history of apnea and bradycardia were more likely to
From the Good Samaritan Hospital, Cincinnati, OH. Address correspondences to Laurie A. Tedeschi, RN, 1075 Stormy Way, Cincinnati, OH 45230. © 2007 Elsevier Inc. All rights reserved. 1527-3369/07/0702-0187$10.00/0 doi:10.1053/j.nainr.2007.03.001
experience apnea and bradycardia as well. This did not occur in randomly selected term infants. Subsequent studies supported these findings.3 Neonatal intensive care units began to implement periods of observation with infants positioned upright in car seats before discharge to monitor episodes of apnea, bradycardia, and oxygen desaturation. Infants born between 34 0/7 to 36 6/7 weeks' gestation are considered near-term/late preterm. Healthy near-term infants admitted to level I newborn nurseries were seldom considered for observation in infant car seats because the risk for adverse cardiorespiratory events was undocumented. Merchant et al4 published a study of 50 term and near-term infants recruited from a level I nursery and monitored for apnea, bradycardia, and oxygen saturation while positioned in infant car seats. The results revealed that 12% of the near-term infants experienced apneic or bradycardic episodes in their car seats, and mean oxygen saturation values declined in the term and near-term infants. Conclusions supported the AAP recommendation of all infants less than 37 weeks' gestation receiving an observation period in an infant car seat, including near-term infants with no specialized nursery care needs. Evidence-based practice integrates critical appraisal of relevant evidence with clinical experience, expertise, and patient preferences and values.5 The Cochrane Database of Systematic Reviews provides resources to assess evidence from randomized controlled clinical trials. In 2005 a systematic review concludes:
“There is no evidence that undertaking a predischarge ‘car seat challenge’ benefits preterm infants. The ‘car seat challenge’ assesses whether preterm infants who are ready for discharge home are prone to episodes of apnoea (stopping breathing), bradycardia (slow heart rate), or desaturation (low oxygen levels) when seated in their car seat. However, it is not clear whether the level of oxygen desaturation, apnoea, or bradycardia detected in the car seat challenge is actually harmful for preterm infants. Additionally, there is concern that use of the car seat challenge may cause undue parental anxiety about the safety of transporting their infant in a car seat. Despite these uncertainties, and despite the widespread use of the test, we have not identified any randomized controlled trials that assessed whether undertaking a car seat challenge is beneficial or harmful to preterm infants.6”
Clinical Experience If the clinical evidence to support practice is imprecise, then what does clinical experience and expertise reveal? Wide variations exist in the evaluation and interpretation of cardiorespiratory stability of healthy near-term infants in infant car seats. In addition, there is inconsistency in recommendations for clinical response to infants who experience physiologic variations in breathing, heart rate, and oxygen saturation. Common clinical practice includes following the AAP guidelines advising that infants experiencing apnea for more than 20 seconds, bradycardia of less than 80 beats per minute, or oxygen saturations below 90% to not travel in the infant car seat. More disparity exists in identifying a course of action for infants who fail to meet the AAP guidelines for cardiorespiratory stability. Some clinicians choose to delay hospital discharge and retest infants at a later date, which is time consuming and expensive. Others elect to transport the infant supine or prone in car bed devices that have recently been designed to withstand collisions but are limited by cost and availability.7 Another alternative is to support posture with blanket rolls or inserts and position the infant car seat at 30 degrees rather than 45 degrees to reduce slouching, which may impact the safety of the restraint system. A pilot study published in 2003 supports the conclusion that episodes of desaturation in infant car seats can be reduced substantially by the use of a simple foam insert that allows the infant to maintain neutral head position.8 Some clinicians report giving infants a respiratory stimulant such as theophylline.9 The AAP recommends the use of a car bed for infants experiencing apnea, bradycardia, or oxygen desaturation during the car seat observation.10 A recently published study of 151 infants weighing less than 1500 grams at birth found no evidence that an event is less likely in a car bed than in a car seat and recommends that whichever device is
used, very low-birth-weight infants require observation during travel.11 Clinical practice diversity exists regarding the length of observation for apnea, bradycardia, and oxygen desaturation in an infant car seat. Timeframes vary from 30 to 90 minutes, with some institutions selecting the timeframe based on the length of the car trip home from the hospital. The practice of individualizing the length of observation is limited by practicality and cost. Neonatal nursing policies published by the National Association of Neonatal Nurses suggest observation of infants in the car seat for 90 minutes.12
Education and Training Implementation of monitoring near-term infants in level I nurseries for a period of observation in infant car seats requires the development of an extensive education and training program for nursing staff and occupies a substantial amount of nursing time in carrying out the observations and educating parents. Because positional car seat testing requires assessment and evaluation, delegation is inappropriate, and the focus of the training and education is the licensed professional nurse. Level I units affiliated with level II or III nurseries may avail themselves of the clinical expertise in those units to develop and implement positional car seat testing policies, training, and education programs. Planning should include hands-on training for nurses in the level I newborn nursery who frequently lack experience initiating and interpreting cardiac, respiratory, and oxygen saturation monitors. Nurses require education and training related to positioning infants in the car seats for testing as well. In addition, documentation of testing data, reporting of results, and parental education should be emphasized during training (Fig 1). An education program for parents and caregivers is essential and should incorporate provisions for parental notification before infant car seat testing (Fig 2) as well as a definition of the responsibilities of the parents and caregivers. The AAP maintains that parents are responsible for the installation of a specific car seat in a specific car, but generic information on the proper use of infant car seats should be provided. Parents should understand that it is the infant's tolerance of positioning in the infant car seat being tested, not the safety of the car seat. Resources and materials used for parent education should undergo periodic review in consultation with healthcare personnel specifically trained by the National Highway Traffic Safety Administration in a 4-day course.1 Specific guidelines for car seat test follow-up include provision of information to the parents. This information encompasses much more than simply reporting the results of the test to the parents or caregivers. Discussion with the parents and caregivers necessitates imparting basic safety information and a clear explanation of the results of the positional car seat testing using terminology they can understand.10 It is important that parents and caregivers recognize that the infant should never be transported in their arms as an alternative to the car seat. Written information supplements education and augments comprehension (Fig 3).
VOLUME 7, NUMBER 2, JUNE 2007
101
Fig 1. Sample flowsheet and policy guidelines for positional car seat testing. The AAP does not stipulate how long positioning restrictions should remain in effect, so parents and caregivers need further instructions to follow-up with a pediatrician or clinic regarding discontinuing positioning precautions.10 Some institutions coordinate appointments before discharge in order to facilitate appropriate follow-up (Fig 3).
Key educational points for follow-up care of infants experiencing apnea, bradycardia, or oxygen desaturation during observation in an infant car seat include the following: • Limiting travel time in the car • Transporting the infant in a car bed • Avoiding the use of swings, infant seats, slings, or any devices where the infant is positioned upright or semi-upright • Direct observation of the infant when positioned upright or semi-upright
102
NEWBORN
Financial Concerns A number of costs occur related to the implementation of car seat testing for the near-term infants in a level I nursery. Some equipment such as cardiorespiratory monitors, oximeters, and loaner car beds necessary for the program need to be procured. Licensed professionals require training and educational inservices. Additional nursing hours are required to assess and evaluate all infants less than 37 weeks' gestation for an observation period in an infant car seat. Equipment costs may be reduced if charitable foundations or grants support the purchase of car beds for loaner programs. Monitors from affiliated level II or level III nurseries undergoing equipment upgrades may be available at low or no cost. Expert nursing staff from regional level II and III nurseries are frequently willing to assist with education and training, allowing the use of a “train-the-trainer” model to increase training efficiency and contain costs. Budgeted nursing hours are still likely to increase in order to support the program.
Conclusion A number of clinical concerns surround the implementation of positional car seat testing in healthy near-term infants.
& INFANT NURSING REVIEWS
Fig 1. (continued) A systematic search and critical appraisal of the clinical evidence and expertise provides some direction during this process. Sharing clinical experiences and continuing to examine the results of related clinical research allows refinement of policies, procedures, and educational programs supporting positional car seat testing of healthy near-term infants.
References 1. American Academy of Pediatrics. Committee on Injury and Poison Prevention: safe transportation of newborns at hospital discharge. Pediatrics. 1999;104:986-987.
2. Willett LD, Leuschen P, Nelson LS, et al. Risk of hypoventilation in premature infants in car seats. Pediatrics. 1986;109:245-248. 3. Bass JL, Kishor AM, Camara J. Monitoring premature infants in car seats: implementing the American Academy of Pediatrics policy in a community hospital. Pediatrics. 1993;91:1137-1141. 4. Merchant JR, Worwa C, Porter S, et al. Respiratory instability of term and near-term healthy newborn infants in car safety seats. Pediatrics. 2001;108:647-652. 5. Sackett DL, Straus SE, Richardson WS, et al. Evidencebased Medicine: how to practice and DBM teach. London: Churchill Livingstone; 2000.
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103
Fig 2. Sample parent letter for use prior to positional car seat test.
Fig 3. Sample parent letter to follow positional car seat test. 104
NEWBORN
& INFANT NURSING REVIEWS
6. Piley E, McGuire W. Pre-discharge “car seat challenge” for preventing morbidity and mortality in preterm infants The Cochrane Database of Systematic Reviews 2005; Retrieved October 19, 2006 from the Cochrane Library web site. www.http://gateway.ut.ovid.com/gw1/ovidweb. cgi. 7. Howard-Salsman KD. Car seat safety for high-risk infants. Neonatal Netw. 2006;25:117-129. 8. Tonkin SL, McIntosh CG, Hadden W, et al. Simple car seat insert to prevent upper airway narrowing in preterm infants: a pilot study. Pediatrics. 2003;112: 907-913.
9. Williams LE, Martin JE. Car seat challenges: where are we in implementation of these programs? J Perinat Neonatal Nurs. 2003;17:158-163. 10. Creehan PA. Sending baby home safely: developing an infant car seat testing program. AWHONN Lifelines. 2002;5:60-70. 11. Salhab WA, Khattak A, Tyson JE, et al. Car seat or car bed for very low birth weight babies at discharge home. Pediatrics. 2007;150:224-228. 12. Altimier L, Brown B, Tedeschi L. NANN guidelines for neonatal policies, procedures, competencies, and clinical pathways. 4th ed. Glenview (Ill): National Association of Neonatal Nurses; 2006.
VOLUME 7, NUMBER 2, JUNE 2007
105