5 - point harness.

Common Errors

There are several common errors made during safety seat use (NHTSA). While correct use is addressed in an instruction booklet that comes with any car seat, there may be many reasons why parents do not follow them. If parents need new instruction booklets, they should call the car seat manufacturer and request them.

Incorrect fit of the harness

Parents leave too much slack in the harness. To effectively secure a child, allow only 1 finger breadth between the child’s shoulders and the harness. Children not snugly secured in their seats have suffered head injuries and even been ejected from the vehicles in which they were riding (Graham, Kittredge, & Stuemky, 1992). Bulky clothing can prevent a snug harness fit. In cold weather, parents should place children into their car seats in indoor clothes, then place a blanket over them to keep them warm. The harness retainer clip should be placed at shoulder level to keep the straps from falling down upon the arms.

Incorrect use. Too much slack. Parent can pull the harness away from the child. Plus the baby can play with it.	Correct Use. Only one finger breadth between the child and the harness
Incorrect use. Incorrect placement of the harness clip down at the child's lower chest / waist area.	Correct Use. Proper use of the harness clip, at the level of the child's shoulders.

Incorrect angle of the car seat

When infant or rear facing convertible seats are placed onto any vehicle seat, they must be placed so that an infant rides at a 45-degree reclined angle. Most automobile seats are not flat; and placing a rear-facing seat into the automobile seat may force a child into an angle which is too upright. To correct this problem, parents can place tightly rolled towel(s) underneath the car seat to level it. A newborn was asphyxiated and died on the way home from the hospital because the child was riding upright, allowing the airway to become occluded (Pennsylvania Chapter, American Academy of Pediatrics, 1995). No car crash had occurred. The hospital and nurse were found liable, because the nurse placed the baby in the car.

Incorrect use. Baby is too upright.	Correct Use. A towel under the seat boosts the angle to 45 degrees.

In contrast to infants, toddlers need to ride upright. If toddlers are in a reclining position and there is a collision, their crotches will absorb the impact of the crash.

Incorrect use. Seat in the reclining position and forward facing.	Correct Use. The car seat is in the upright angle in the forward facing position.

Incorrect threading of the harness

In the rear facing position, the harness needs to be at or below the level of the baby’s shoulders. The harness holds the infant down into the seat.

Incorrect use. The harness is above the baby's shoulders in the infant position.	Correct Use. The harness is below the level of the infant's shoulders.

In the forward facing position, the harness needs to thread through the top-most slots unless the manufacturer instructions indicate otherwise, to take advantage of the reinforced plastic to support the heavier child.

Harness threaded through the top slots. Observe the thickness of the plastic at that level, the car seat needs that strength to sustain a heavier child in a car crash.	The back of the car seat with the harness in the lower slots.
Incorrect use. The harness is in the lowest slots, clearly below the level of the child's shoulders.	Rethreading the harness into the top slots.

Incorrect placement of the car seat into the vehicle

When a car seat is placed into a vehicle and the seat belt fastened around it, it should be secure and not move any more than 1 inch from side to side or forward on the vehicle seat. If it moves more than 1 inch, the seat may tip when the car goes around a corner, and/or fail to hold the child in place in a crash. To obtain a secure placement, parents should press down on the seat with their weight and pull the seat belt taut. If the seat is in a lap-shoulder belt position, it may need a locking clip. A locking clip fastens the shoulder and lap belt together to hold the lap part tightly around the seat when correctly used. Parents should check the owner’s manual of their vehicle to find out whether they need a locking clip; and if not, how to pull the seat belt taut.

An example of a seat tightly secured into a vehicle.

Failure to correct a recall

Parents should register any new seat with the car seat manufacturer and inform the company of a new address if they move. Some recalls correct relatively minor problems, while others are for problems, which could result in serious injury or death if not corrected. To find out if their seats have recalls parents should call NHTSA’s Auto Safety Hotline at 800.424.9393.

Failure to replace parts and pieces if they are lost or damaged

All parts and pieces are important to car seats. If lost or broken, replacements can be obtained from the manufacturer. Using safety pins to replace metal slides or wooden bars to replace metal ones could be deadly.

Placing children in the front seat

If possible, children should ride in back seats until they are at least 13 years old. Children sitting in the back seat of any vehicle have a 26% lower fatality rate than those sitting in front seats (NHTSA, 1997).

Failure to replace a seat which has sustained a crash with a child occupying it

All car seats should be replaced if they are involved in a crash with the child riding in them. The plastic shell and the harness absorb the impact of a crash only once, and cannot be guaranteed a second time. Most insurance companies pay for a new seat as part of repairing the vehicle. Parents must be advised to contact their insurance agents and explore that possibility.

Used seats

Used seats may be acceptable if financial constraints make the purchase of a new seat difficult (Safety Belt Safe, U. S. A., 1996). If parents choose this alternative; they need to obtain the instruction booklet, make sure that all of the parts and pieces are there, reliably find out the history of the seat, and check for recalls. If it is impossible to learn whether the seat has been in a crash, it should not be used. There is no way to tell by looking at a seat whether it has, or has not, been in a crash. Most manufacturers recommend replacing seats after 5 years.

Conclusion

The American people now have many choices as to whom they will seek to provide their primary care; they can choose between nurse practitioners, physicians, naturopaths, osteopaths, and physician assistants. Insurance companies also make choices as to which groups they will reimburse; as well as deciding how much, for varying groups. Nurse practitioners have been shown to spend more time with their clients, and can capitalize on their communication strengths to make even better use of their injury prevention counseling. If nurse practitioners take advantage of their abilities to practice the positive aspects of both the nursing and medical models, it will increase their credibility, as well as enhance their position as primary care providers. A strong and sound knowledge of car seat usage, as well as the ability to impart the information effectively to families served, can help increase the health of individuals, families, and society.

Resource List

Air Bag & Seat Belt Safety Campaign
1025 Connecticut Ave., NW
Suite 1200
Washington, DC 20036
E-mail: airbag@nsc.org.

Car Seat Manufacturers
    Century 800.837.4044
    Cosco 800.544.1108
    Evenflo 800.233.5921
    Fisher Price 800.432.5437
    Gerry 800.525.2472
    Kolcraft 800.453.7673

Governor’s Highway Safety Office - call directory assistance in your state

National Safe Kids Campaign 202.662.0600

National Highway Transportation Safety Administration Hotline 800.424.9393

References

American Academy of Pediatrics, Philadelphia Chapter, American Academy of Pediatrics, 141 Northwest Point Blvd., P. O. Box 927, Elk Grove Village, IL 60007.

Bass, J., Christoffel, K. K., & Lindome, M., et al. (1993). Childhood injury prevention counseling in primary care settings: A critical review of the literature. Pediatrics, 93 (92), 544-550.

Brockenbrough, M. (1994, June 12). Tough little kid is facing risky, rare transplant. The News Tribune, B1, B2.

Foss, R. D. (1989). Evaluation of a community -wide incentive program to promote safety restraint use. American Journal of Public Health, 79(3) 304 -306.

Geilen, A. C., Mc Donald, E. M., Forrest, C. b., Harvilchuck, J. D., & Wissow, L. (1997). Injury prevention counseling in an urban pediatric clinic. Archives of Pediatric and Adolescent Medicine, 151, 146-151.

Graham, C. J., Kittredge, D., & Stuemky, J. H. (1992). Injuries associated with child safety seat misuse. Pediatric Emergency Care, 8 (6), 351-353.

Kohn, A., (1995). Punished by rewards. New York: Houghton Misslin.

Maraldo, P. J. K. (1993). Politics and policy in primary health care. In: M. D. Mezey, D. O. McGivern (Eds.). Nurses, nurse practitioners: Evolution to advanced practice (pp. 342-370). New York: Springer Publishing Company.

Miller, T., Demes, J., and Bovbjerg, R. (November 1993). Child seats: How large are the benefits and who should pay?, in Child Occupant Protection, Warrendale, PA: Society of Automotive Engineers, (pp. 81-90).

National Highway Transportation Safety Administration, Traffic Safety Facts, (1996a) National Center for Statistics & Analysis, Research & Development, Washington, D. C., 20590 [http://www.nhtsa.dot.gov]

National Highway Transportation Safety Administration (1996b) Observed patterns of misuse of child safety seats. Traffic tech. NHTSA Technology Transfer Series, 133. Safety Belt Safe U. S. A.

National Highway Traffic Safety Administration (1997) Standardized Child Passenger Safety Program

National Highway Transpiration Safety Administration, Are you using it right? NHTSA.

National Safe Kids Campaign. Motor Vehicle Occupant Injury Fact Sheet [www. safekids.org.]

Passenger Safety Education Materials. Safety Belt Safe U. S. A. 123 West Manchester Blvd. Inglewood, CA 90301.

U. S. Dept. of Health and Human Services (1990). Healthy People 2000. Washington, D. C.,

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