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Putting a newborn baby in a car seat is daunting even in the best of circumstances. They are just so tiny and fragile, the buckles on the seat seem so huge and it often feels like you’re just going to smush (technical term) their insides when you tighten the harness. As they grow, they feel less breakable, but it seems there’s always something new to worry about when it comes to car seats.

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 to address this issue, but as a Pediatric Physical Therapist and a CPS Technician, I have some grave concerns that these “solutions” to head slump might be much worse than the problem itself.

What is head slump?

You know when your husband sits next to you on an airplane and immediately falls asleep while you are stuck alone, anxious and bored out of your mind for the next 3 hours? (No? Just me?) Well, that moment when they’re so deeply enjoying their abandonment nap that their head falls forward is “head slump”.

Head slump is 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’s 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 mobile than ours and much less prone to tightness from tension, so the forward flexed head isn’t usually painful for them. The person sleeping on the airplane isn’t in any danger from their head slump 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 typically 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’re 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 (hopefully) be appropriate for a newborn. But there is no option to make the seat more upright for an older baby with good head control.

 

Other seats just have an undifferentiated 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 (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. They are not in any danger from having their head dangling forward. I’ve ignored the situation with my two older kids and it’s never been an issue.

If your older baby or toddler is experiencing head slump while rear-facing, it may be possible to increase the recline angle of their seat. 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 up their seat and hitting the vehicle seat behind them in a frontal crash. So proceed with caution before you make the decision to increase the recline 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 dangerous than a potential head injury in a crash. More info on that concern can be found in this article.

If your child is riding in a forward-facing convertible 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 is more reclined and can be better overall for sleeping.

You can also consider buying a car seat which offers more than one recline position for forward-facing. The Chicco NextFit, Chicco MyFit (pictured right), Nuna Rava, Clek Foonf, Graco 4Ever (recline positions are dictated by child’s weight), Graco 4Ever Extend2 Fit (recline positions dictated by child’s weight), Graco Extend2Fit (recline positions dictated by child’s weight), Maxi-Cosi Pria (pictured below – recline positions dictated by child’s weight), Britax Marathon CT, Boulevard CT, Advocate CT, Britax Frontier and Pinnacle, and surely a few others I’m missing all allow some degree of recline when forward facing, though this may or may not eliminate head slump depending upon the child and vehicle.

A cheap and easy way to reduce head slump is to place 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.

What NOT to do about head slump

In the past several years a multitude of aftermarket (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 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 chest clip 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 special needs 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.