One of the most common questions I see on parenting and car seat groups is regarding head slump, typically in forward-facing kids or in older rear-facing children. There are new aftermarket products coming out each day that promise to “fix” this issue, but as a Pediatric Physical Therapist and a CPS Technician, I have some grave concerns that these “solutions” to head slump might actually be much worse than the problem itself.
What is head slump?
The term “head slump” is used to describe a position of the head when the chin moves towards the chest in a moment of forward flexion of the cervical (upper) spine. It is most common when a person is sleeping upright, and to an adult, it can be pretty uncomfortable. Adults are not terribly flexible and some of us carry a tiny little bit (okay, a ton) of tension in our necks. But thankfully, our kids don’t. Their necks are more flexible than ours and much less prone to tightness from tension, so the forward flexed head isn’t usually painful for them.
The adult with head slump sleeping on an airplane isn’t in any danger from their head position and likewise, for most kids, it’s really a non-issue.
When is head slump something to worry about?
The first and most common scenario where head slump is a real problem is in a newborn. The airway in a newborn baby is tiny, about the diameter of a drinking straw, and often it’s a little more flexible than an adult’s, meaning it’s easier to partially block or collapse.
Another reason head slump can be concerning for a newborn is that they may not have the neurological drive to reopen their airway. That is, their brain may not be developed enough to realize that it’s being deprived of oxygen or to tell the muscles to do something about it. Finally, because newborns have proportionally large heads on tiny neck muscles, even if they have the drive to lift their heads, they often lack the strength to make that lift against gravity.
The other situation where head slump is a concern is in older children who do not have adequate head control. These are children with medical diagnoses of some sort and the problem is essentially the same as in a newborn – if a child cannot lift and maintain their head upright against gravity, then they need to be positioned to make sure that head slump does not occur. The same goes for babies with tracheomalacia, where the trachea is not as rigid and may be more prone to collapse.
These two groups aside, head slump is not a problematic position for typically developing children and older babies. These children have wider airways, the ability and awareness to lift their heads if they’re not getting adequate air, and the position itself isn’t inherently dangerous for the neck. There’s not a universal age where this happens, but once baby can fully lift their head and hold it up to look around for a few minutes during tummy time, they are likely in the clear.
What should you do about head slump?
With a newborn, make sure you have achieved the maximum rear-facing recline angle allowed by the car seat. Some seats have a specific newborn recline angle indicator within the overall range of acceptable recline positions.
Some seats have a single level-to-ground line that should be appropriate for a newborn but there is no option to make the seat more upright for an older baby.
Other seats just have an acceptable range of recline. If your seat does not have a newborn recline angle specified, for the first several months, you will want to install the seat or the base so that it is reclined as far back as possible but still within the allowed range.
For a child with special medical needs, including poor head control, you will want to rear-face as long as you can to offer the most head and neck support and use the deepest recline allowed for your seat. If the child is too big for a rear-facing seat, you can look into a forward-facing seat with recline options or a specialized medical seat with positioning features or inserts. Even in these cases, you should not exceed the approved recline for your child’s size, per the instruction manual.
For a typical older child with head slump, your first and easiest option is to do nothing. I know it looks awful and uncomfortable but I promise that they are in zero danger from having their head dangling forward while sleeping. I’ve ignored the situation with all 3 of my kids and it’s never been an issue.
However, if you are determined to try to alleviate, or at least reduce, the head slump your child is experiencing while asleep, here are some safe and reasonable things to try.
For an older baby or toddler is experiencing head slump while rear-facing, it may be possible to recline their car seat a bit more. However, the downside of this is that bigger, heavier kids in very reclined rear-facing seats may be at higher risk for head injuries from “ramping” in a frontal crash. Proceed with caution before you make the decision to increase the recline angle on your older child’s rear-facing seat just to deal with a head slump issue. A potential sore neck after a nap (which is unlikely anyway) is much less risky than a potential head injury in a crash. More info on ramping can be found in this article.
If your child is riding in a forward-facing convertible or all-in-one seat and head slump is concerning to you, you may be able to return to the rear-facing position if your child is still under the RF weight and height limits of your seat. A rear-facing convertible/all-in-one is more reclined and can be more comfortable overall for sleeping.
For older children who are forward-facing, you can also consider a car seat which offers more than one recline position for forward-facing.
The Chicco NextFit convertible, Chicco OneFit All-in-One, Chicco Fit4 All-in-One & Chicco MyFit Harness + Booster all allow a slightly reclined position when the child is forward-facing but you have to stay within the FF range allowed by the liquid bubble level indicator.
The Britax One4Life All-in-One, all three Britax ClickTight Convertible models (Marathon, Boulevard & Advocate), & Britax Grow With You ClickTight Harness-2-Booster (forward-facing only), also allow a slightly reclined position when the child is forward-facing. The One4Life & the convertible models require the forward-facing recline angle to be within the FF range allowed by the level indicator.
Graco seats can be a little deceiving because the forward-facing recline positions are dictated by the child’s weight and those positions vary from one Graco seat to another. Example: the Graco 4Ever DLX 4-in-1 allows the use of recline positions 4 or 5 (4 being more reclined) but only when the seat is forward-facing for children under 40 lbs. For children over 40 lbs., the 4Ever DLX must be installed in the fully upright position 6.
The NEW Graco 4Ever DLX Grad 5-in-1 allows more flexibility in the recline positions you can use for a forward-facing child. This model requires forward-facing children under 25 lbs. to use recline position 4, and it requires children over 50 lbs. to use the most upright position 6. But for all forward-facing kids between 25-50 lbs., you can chose to install in recline positions 4, 5 or 6. This flexibility is a big improvement over the standard 4Ever DLX model.
If you’re not in the market for a new seat and you’re searching for a cheap and easy way to reduce head slump – try placing a sticker on the ceiling of your car, above your child’s seat. If they start to fall asleep, you can have them look up toward the sticker, which will keep them more upright in the seat and may prevent, or at least delay, head slump during their nap.
Now let’s talk about what NOT to do:
In the past several years a multitude of aftermarket (aka, non-regulated) products have been created to combat the head slump “dilemma”. Most of them are fairly similar in style – usually a fabric strip or sling of some sort, with elastic or velcro that attaches to the car seat. When the child starts to fall asleep you’re supposed to move the fabric piece over the forehead to help keep the head up. I don’t know how you do this safely while driving, but that’s kind of a secondary worry. These devices terrify me. They are not a solution for head slump, and should never be used for any child in any car seat, period.
For starters, every car seat on the market expressly prohibits the use of aftermarket (non-regulated) products, which means that if something happens, your car seat manufacturer could be absolved of all liability. More concerning, however, is the stress that these products could place on the neck in the event of a crash when used forward facing in a harness or booster.
The first picture below is my son pretending to forward face with a mock sling on his forehead. When he’s upright in a pre-crash position his head (blue circle) is aligned on a relatively neutral spine (green line). The following picture attempts to show what the alignment would look like during the first few milliseconds of a frontal crash. Even if the sling only held his head back for a fraction of a second, it could be enough to alter the alignment of his head, neck, and spine, while the torso moves forward first. You can see the huge curvature of the upper spine (curved green line). There are several delicate ligaments that are critical for spinal stability that could be torn, not to mention the potential for multiple fractures, especially on the back side of the spine where it is compressed. Once the sling slips off, the head will make the range of motions that it would have made from the start, without the sling. The concern is that the head and neck will go through an even greater range of motion since the head was briefly held back when the torso began moving forward. Whenever you have increased motion on the neck, there’s an increased risk of a very substantial spinal injury.
I can’t stress this enough – holding the head back, even for a millisecond, while the torso moves forward with great force in a frontal crash, is going to harm the neck. The physics of this are dangerous and potentially even fatal.
With a rear-facing child, the risk may seem less severe but we shouldn’t assume that. In a frontal crash, the child will ramp up significantly in the seat and the sling may end up on the child’s throat which could cause significant injury to their airway. Even if that doesn’t happen, we still need to consider the secondary “rebound” motion that the rear-facing child experiences in the late phases of a frontal crash. And of course, there are concerns about what might happen in a rear-impact crash. Even without a crash, these slings can slide out of place and could be a strangulation or smothering risk, especially for a baby.
Bottom line, these aftermarket products are just not safe. Even if they claim they’ve been crash tested, there is no way to know what that means since there are no safety standards for these products to pass or fail. Even if it was attached to a child dummy during a certified FMVSS 213 crash test, there’s still no way to know how it would affect a real child who might use it.
What should you do if you’re still concerned about head slump?
Find a local CPS Technician using Safe Kids’ website here. Have the technician check your installation to see if more recline could or should be used with your seat. Have them check the harnessing too to determine if a snugger harness or improved placement of the harness height and headwings could help prevent or reduce the head slump. If everything is as it should be, and your child isn’t a newborn or an older child with low tone and poor head control, try the sticker on the ceiling suggestion. If that doesn’t work, just try to let it go. Head slump happens sometimes, but it’s really not a concern for neurotypical older babies and kids. It may look scary or uncomfortable but in an older baby or child, the risk of something bad happening because of head slump is virtually non-existent.
Adding aftermarket products to a car seat to prevent head slump is absolutely more risky than what you are trying to prevent.