Restraints for Children with Special Health Care Needs

Conventional Car Seats

Conventional car seats are appropriate for many children with special health care needs. Conventional car seats are defined as those restraints that meet Federal Motor Vehicle Safety Standard 213 (FMVSS 213). Conventional restraints can be purchased at retail stores and are not specifically designed for children with special health care needs. Examples include rear-facing only car seats, convertible (and all-in-one) car seats, combination car seats, and belt-positioning booster seats. Car seats with harnesses up to 40-50 pounds rear-facing and 65 pounds forward-facing have increased the number of conventional car seat options available for children with special health care needs.

Many conventional convertible car seats and conventional all-in-one car seats also have multiple recline angles in rear-facing and in forward-facing. These recline angles may benefit children with decreased head control, low tone, and many other diagnoses. Rear-facing car seats will have the most recline angle.

American Academy of Pediatrics Conventional Car Seat Product Listing – Includes weight and height limits, pricing, and is separated by Rear-Facing Only Seats, Convertible Seats (All-in-One Seats) Combination Seats, and Belt-Positioning Booster Seats, Travel Vests, and Other Seats.

Rear-Facing Only Seats

Rear-facing car seats, which include rear-facing only car seats and convertible car seats, provide appropriate postural support and protection for many children with various medical conditions. Weight maximums as high as 30-35 pounds in rear-facing only car seats and as high as 40-50 pounds in rear-facing convertible car seats allow some children with complex health care needs to ride rear-facing longer.

Many rear-facing car seats come with infant positioning inserts and head support systems that provide adequate lateral support and head support for infants. Some inserts are designed specifically for use by smaller infants or infants born prematurely.

Select car seats with smaller internal dimensions for smaller infants who do not experience cardio-respiratory events. If infants weigh less than five pounds, select a car seat with a lower minimum weight limit with many starting at 4 pounds and some starting at 3 pounds. Some infants born with low birth weight or born prematurely may require a Car Seat Tolerance Screening - which allows medical professionals to monitor vital signs while in the chosen car seat. This is to ensure that the infant is safe to travel home from the hospital in the car seat. Health care professionals must maintain an appropriate angle during Car Seat Tolerance Screening and also during vehicle installation to ensure the infant is ready to travel in the chosen car seat.

According to current safety recommendations, children are best protected in a crash when rear-facing in the appropriate car seat as long as possible, until the they have outgrown the rear-facing weight limit or height limit for that particular car seat. Many convertible car seats can be used rear-facing to weights as high as 40-50 pounds. These car seats allow larger infants and toddlers with special health care needs to ride rear-facing longer.

Conventional convertible/all-in-one rotating car seats (aka swiveling, revolving, etc.) also allow children to stay rear-facing longer. The rotation allows transferring into the car seat to be easier for the caregiver and child.

Convertible Car Seats

In general, convertible car seats are designed for rear-facing use for infants and forward-facing use for toddlers/children. They are “converted” by making specific changes, according to manufacturer’s instructions. Convertible car seats also include all-in-one car seats.

Keep your child rear-facing as long as possible. Staying rear-facing helps support your child’s entire body and protects better from an injury, especially to the spine. Most convertible car seats are approved for rear-facing up to 40-50 pounds and should be considered for infants whose height and weight have exceeded the limits of the rear-facing only car seat (Check manufacturer’s instructions for weight limits). Move your child into a rear-facing convertible/all-in-one car seat when outgrowing the rear-facing only car seat. Convertible/all-in-one car seats that are rear-facing to higher weights can also be beneficial to many children with special health care needs. For example, children of smaller stature, developmental delays, brittle bones, down syndrome, hydrocephalus, low tone, and with decreased upper body control will be better positioned and best protected when riding rear-facing.

Forward-Facing Car Seats

Forward-facing car seats, including convertible seats and all-in-one car seats, with upper harness limits up to 65 pounds . These forward-facing car seats provide many children with special health care needs the opportunity to benefit longer from the protection offered by a five-point harness.

Some features that may benefit children with special health care needs are as follows:

Five-point harnesses that can be used up to 65 pounds provide many children with more time in a harnessed restraint for children if there are behavioral challenges, positional issues, or obesity.
Forward-facing car seats with multiple recline options may assist with positioning children with poor head and neck control and who have outgrown the rear-facing limits of their car seats.
Extra padding and positioning inserts that come with that particular car seat can provide better positioning or comfort for children with neuromuscular or bone dysplasia conditions.

Belt-Positioning Booster Seats

In order to use a belt-positioning booster seat, a child with special health care needs must have good head, neck, and trunk control. Boosters with higher weight limits may be suitable for children who are overweight or obese. Extended booster use is recommended for children smaller than their typically developing peers, such as children with achondroplasia. High back boosters with sides may provide adequate lateral support for some larger children who experience tire without support or have fluctuations in trunk control. Booster seats may also assist with children with behavioral challenges by improving their comfort and positioning by allowing their knees to bend and their legs to hang down appropriately. This may also improve behavior as the child is able to see out the window.

Adaptive Restraints

In general, adaptive restraints are car beds, large medical seats, booster seats, and vests designed specifically for children with special health care needs and are not available at retail stores. They are ordered through a local durable medical equipment vendor or in some cases ordered directly from the manufacturer. Evaluations by trained, skilled therapists are required by most insurance companies. Adaptive restraints are more expensive than conventional car seats and funding can be challenging. Adaptive restraint loan programs may be available through hospitals, local Easter Seal affiliates, health departments, and Safe Kids coalitions. Insurance coverage may pay the cost of adaptive restraints following an evaluation where the therapist completes a Letter of Medical Necessity, and the additional required documentation is provided.

National Center for the Safe Transportation of Children with Special Health Care Needs Brochure – This brochure includes images and information on currently available adaptive restraints.

The following section includes general information about categories of adaptive restraints. It does not provide information about specific restraints.

Car Beds

Car beds are designed for infants who must travel lying down. Car beds may needed for infants who have cardio-respiratory conditions, lower extremity casts, omphaloceles, midline chest defects, abdominal defects, or neuromuscular disorders. Use of car beds should be for those infants who demonstrate a medical necessity and MUST travel lying down. Infants who are recommended to travel in a car bed should complete a Car Seat Tolerance Screening prior to discharge to ensure positioning in the car bed will not exacerbate any of the infant’s symptoms. Additionally, when the physician determines the infant may transition to a conventional rear-facing car seat, an additional Car Seat Tolerance Screening in the specific rear-facing car seat should be completed to ensure the infant is capable of the transition to a rear-facing position without exacerbating symptoms.

Current car beds include the Angel Ride, Dream Ride, and Hope Car Bed.

Adaptive Rear-Facing Only Seat for Children with Omphaloceles

One rear-facing only adaptive car seat is specifically designed for a child with an omphaloclele (Jefferson RFO Adaptive Car Seat), however can be used for any child who needs the yoke harness system. The yoke harness system that routes around the abdomen and has an adjuster on each harness to compensate for irregularities. Consult with the child’s healthcare team to determine the best options.

Adaptive Restraints for Children in Casts

There are adaptive restraints designed specifically for children in casts. Each restraint offers its own method of accommodating hip casts (i.e., hammock, wedges, inserts, etc.), but all feature a wide base with low-profile. These restraints vary from car beds and vests for lying down, convertible car seat to forward-facing only car seat. Each restraint has a different weight and height range.

Current options include the Hope car bed, convertible Wallenberg, forward-facing Spirit Spica, and Lay Down EZ-ON Vest (formerly Modified EZ-ON Vest). For some children who do not fit within the previous restraints – non-emergency professional medical ambulance transport may need to be considered.

Large Medical Seats

Large medical seats are designed for children who have outgrown conventional car seats and/or require additional positioning support or additional accessories not available in a conventional car seat. Upper weight limits range from 102-130 pounds and upper height limits range from 60-66 inches depending on the restraint. Anti-escape options are also available on specific adaptive restraints for children who may be unbuckling or escaping the current conventional car seat.

It’s important for families to work with an occupational therapist (OT) or physical therapist (PT) who has experience working with pediatric patients and is a child passenger safety technician (CPST). OTs or PTs will be able to evaluate a child’s positioning needs and determine which restraint provides the best positioning options for the child. Some OTs and PTs who are not CPSTs can work together with a CPST to determine positioning needs and which restraint is best for a child.

Current large medical seats include the Defender Reha, Roosevelt, MPS Car Seat, Spirit, and Spirit Plus.

Adaptive Booster Seats

Adaptive boosters must be used with the vehicle’s lap-and-shoulder belt system to provide occupant protection. The harnesses and vests in adaptive booster seats are for positioning only to provide supplemental support to a child with special health care needs. Depending on the booster, they may also have accessories that aid with positioning, such as abductors/pommels, lap trays, foot rests, and rotating bases. Upper weight limits range from 108-176.4 pounds, with upper height limits range from 60-72 inches depending on the restraint.

Current options include the Carrot 3 Child Restraint, Carrot 3 Booster, Churchill, Soft Touch Booster, Recaro Monza Nova Reha 2, and Hercules Prime.

Adaptive Vests

Adaptive vests are designed for children with special health care needs for use in passenger vehicles. Upright, seated vests usually fit children from 2 years of age and 31 pounds up to 225 pounds. Some adaptive vests can be ordered with rear zipper closure systems to decreased escaping behaviors. Typically, an upright vest will not provide adequate support for a child with poor head, neck, and trunk support.

The Lay Down EZ-On Vest/503 (previously the Modified EZ-ON Vest) is for children ages 1 year and older and 22-106 pounds. The child must be able to fit lengthwise on the vehicle bench seat. This vest is an option for children in hip spica casts or for older children who must lie down during travel.

Current adaptive vest options include the Chamberlain, EZ-ON 303Z, EZ-ON 403PB, EZ-ON Max PV, and Moore Support Vest.

Additional adaptive vests are also used in school buses.

Adapted Vehicles/Wheelchair Accessible Vehicles

Some families may require use of adapted vehicles in order to meet the transportation needs of their children. The National Highway Traffic Safety Administration (NHTSA) publishes a brochure, “Adapting Motor Vehicles for People with Disabilities,” to assist families to navigate the process of securing adapted vehicles. In general, NHTSA recommends that families work with a driver rehabilitation specialist who is qualified to assess the family’s specific transportation needs and provide them with a list of appropriate vehicle modifications. Although driver rehabilitation specialists typically work with drivers with disabilities, they can also evaluate the vehicle needs of passengers with disabilities. Names of qualified evaluators can be obtained by contacting a local rehabilitation center or the Association for Driver Rehabilitation Specialists at aded.net.

Once the vehicle modifications have been evaluated and discussed with the family, appropriate vehicle options can be explored. When choosing a vehicle, it is important for families to work with a reputable dealer of adapted vehicles. The vehicle should be equipped with seat belts, vehicle seats, and tether anchorage locations that meet all applicable federal safety standards. The vehicle seat belts should be capable of remaining locked during normal driving conditions if car seats are installed. If the vehicle is adapted to accommodate use of a wheelchair, it should provide adequate space for the wheelchair to face forward, use a four-point tie down system, and a separate three-point seat belt for the wheelchair occupant. In addition, the vehicle should be equipped with appropriate restraint systems for all other occupants.

New adapted vehicles/wheelchair accessible vehicles can be expensive – adding $10,000 to $30,000 to the traditional sticker price. NHTSA suggests that families pursue both public and private avenues for funding the vehicles. For example, insurance companies may cover costs associated with evaluations and vehicle modifications. Adapted vehicle manufacturers may offer rebates or reimbursement plans. Social service agencies may be able to help families explore applicable grants.

Rotating vehicle seats – like the BraunAbility Turny Evo Seat – are also available. If purchasing an adaptive vehicle or wheelchair accessible van is cost-prohibitive, a rotating vehicle seat may be an option. The rotating vehicle seat moves out and next to the vehicle making transfers safer and easier to from a wheelchair to the vehicle seat.

Wheelchair Information

If possible – your child should ride in the appropriate restraint in the vehicle seat instead of the wheelchair. If transferring is not possible, or if the rider requires the support of the wheelchair seating system, it is very important to secure the wheelchair to the vehicle with the appropriate tie-down system and secure the rider in the wheelchair with crash-tested lap-and-shoulder belt . Lap belt angles between 30-75 degrees to vertical are recommended. Both the wheelchair and the rider should face forward in the vehicle. The use of a transit-equipped wheelchair that has been crash tested is safer to use in a vehicle as it will have the appropriate tie-down locations. If your child is transported in the wheelchair on the bus or the family vehicle you can find a detailed information at the University of Michigan Wheelchair Transportation Safety website describing best practices when using a wheelchair as a transportation device in a vehicle.

MISCELLANEOUS

Head/Neck Collars

A child who has decreased head and neck control will eventually need to be positioned forward-facing in a vehicle. Although there are neck collars that provide supplemental neck support, their use during transport in vehicles is of concern. Crash testing of a variety of neck collars indicate that most models increased neck tension. The crash tests suggest that stiff and formed neck collars should be removed prior to transport and replaced with softest, foam cervical collars during travel. A change from a rigid neck collar to a soft cervical collar must be approved by the physician who prescribed the rigid neck collar with a written order – as this is not a caregiver or CPST choice.

Note: A child’s head should never be secured to a restraint in an attempt to prevent the head from falling forward. Many items are sold online and elsewhere – however they are not safe to add to any conventional car seat or any adaptive restraint. With that said – there is one exception that has been crash-tested to be used with two specific restraints. Merritt Manufacturing Roosevelt large medical seat and Merritt Manufacturing Churchill adaptive booster seat have a cap with a Velcro attachment that has been crash-tested. No other car seat or restraint can use the Merritt Manufacturing cap accessory at this time.

Medical Equipment

Medical equipment can quickly become a projectile. To date, there is no product available designed specifically to secure medical equipment, such as apnea monitors or oxygen tanks, in a vehicle. There are studies occurring now for products. Current recommendations for securing equipment include placing it on the floor as low as possible in the vehicle wedged with pillows, foam, or blankets. Some newer vehicles have airbag sensors under vehicle seats that might not allow medical equipment to be placed under the seats. Refer to the specific vehicle owner’s manual for details. If a vehicle prohibits placing items under a vehicle seat – securing the medical equipment with vehicle seat belts in unoccupied vehicle seats is also an option.

Modifying Restraints

Conventional car seats or adaptive restraints that have been structurally modified should not be used unless they have been crash tested with the modification to conform to federal motor vehicle safety standards. What might seem like a minor structural modification can greatly compromise the performance of the restraint in a crash and place your child in danger for serious injury. Please refer to specific manufacturers for details.