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Head Slump: When it’s a Problem and How (Not!) to Fix it

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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?

You Asked: How do I keep my kids safe when someone else is driving?

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While it may sound like an exaggeration, I find driving my own kids around to be kind of scary, because while I can control my car seats and the way I’m driving, no matter how hard I try I can’t control other drivers. But that fear doesn’t hold a candle to the fear of sending my kids off in someone else’s car. When someone else drives my children, not only am I not in control of any of the drivers, but I’m also not usually in charge of the car seating either. And a few years ago, this concern came to life in the scariest way.

While I was in labor with my second son, my husband got a phone call. He wouldn’t tell me what it was about since we had enough going on in that moment, but once the baby was safely delivered, he told me that the call had been to let us know that our oldest child had been in a crash. Thankfully, he was fine because it was a minor collision and because the driver had installed his seat correctly and had buckled him in properly. It was the best outcome of a personal worst case scenario.

When a friend asked me how to help keep her baby safe when someone else was driving him around, I realized that it’s not a topic we spend enough time covering. I’d like to share some of the tips I’ve developed that give me peace of mind when other people drive my kids.

You Asked: How do I keep my kids safe when someone else is driving?

First and foremost, never let someone talk you into something that doesn’t feel safe or isn’t legal. This is a good life mantra in general, but I mean it specifically for child passenger safety today.

It doesn’t matter if grandma finds a booster seat to be more convenient – if your child isn’t ready, it isn’t the right choice. It doesn’t matter if your aunt thinks he looks so cramped rear facing, if your child isn’t 2 yet or if you just aren’t ready to turn him around, don’t do it. You are the boss of your kids, don’t be afraid to make the tough, but safe, choice for your child. Don’t let anyone make you feel bad for your choices either.

Now that that’s out of the way, there are several ways to help keep your child(ren) safe in someone else’s car.

If you can, install their seat yourself and demonstrate harnessing with your child in the seat. If possible, you even want to be the person who does the final buckling before they drive off. This is the gold standard in an ideal situation, but it’s also not possible a lot of the time so you may have to get a bit more creative.

If installing the seat yourself isn’t a possibility, talk your child’s caregiver through the process ahead of time, when time isn’t limited and there’s no pressure. Also, provide them with a manual that you’ve reviewed recently. My trick is that I pull the digital version up on my phone so that if there are questions, I can easily refer to the manual myself and give tips. This actually helped me out just last month when my son’s babysitter needed to remove his (latched) booster out of her car before I got there and she didn’t know how to do it. I was able to scroll through the manual, find the page and show her what to do.

If the person isn’t confident with the installation or you want to offer an extra support, you can send links to youtube installation videos. I’m sure some will think this is overkill and that’s fine, but I am of the mind that I’d rather offer too much help than not enough.

Once you’re confident with the installation, show the caregiver how the harness should be, in person if possible. If your child will be wearing the same clothes the whole time they’re with this caregiver, you can get them harnessed in the seat and then remove them from the seat without loosening the straps so it’s appropriately tight. If you do this, make sure to show how to tighten and loosen the harness, just in case your caregiver needs to. If you can’t demonstrate in person, showing them images like these can help.

If your child is old enough to understand and remember, start teaching them car seat rules. My 3 and 5 year old know where their chest clips go and that their harness should feel “snug as a hug”. We started working on this when they were 2 years old, though it takes some time and repetition. Every time I buckled them, I would have them show me where the chest clip should be. Then I would tighten and ask if they were “snug as a hug.” Once I felt like they had a good grasp on the idea, I would occasionally not tighten them fully and see how they responded when I asked if their harness was snug. Truthfully, teaching my kids this has even saved me on several occasions when I’ve started to back out of our driveway without tightening the straps on my 5-year-old who buckles himself, but cannot tighten the straps on his own.

Teaching your kids how their seat should feel and be positioned, and that it’s okay to speak up about it (politely, obviously), will go a long way towards keeping them safe when you can’t be with them.

So, you asked: how do I keep my kids safe when someone else is driving and the simple answers are:
  1. Install the seat yourself, or make sure the person installing it knows exactly what to do.
  2. Demonstrate proper harnessing or show pictures so they know exactly what to do.
  3. As your children acquire language and an opinion, teach them what proper usage should look and feel like so they can advocate for themselves.

More on keeping kids safe in the car:

5 Tips for Sharing Carseat Tips with Friends

Tweenbelt Safety

You Asked: When is the right time to move to a booster?

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A few weeks ago, I wanted to write something but no matter how long I stared at my computer, I couldn’t come up with anything interesting to write about. After an embarrassing amount of time, I took to my social media channels and asked my friends what their top car seat question was. I found a lot of commonalities among the things people offered up because there are definitely some areas of car seating that are more difficult than others, but there was a wide variety of things people want to know more about. And after looking through the responses and sitting on it for a bit, I’m going to use those suggestions (and new ones that come along), to launch a new series of articles.

I decided my first “You Asked” post would be whichever topic came up the most from my friends, and the result ended up being one of the questions I get most often in person from friends and family, so it feels right to start here.

You Asked: When is it time to switch to a booster?

I think boosters are confusing because all the seats you’ve used up to this point have been sort of similar. They all install in a relatively similar pattern, the way you secure your child is consistent, but then you get to boosters and they don’t install the same way and they don’t work the same way and it’s just hard to know if you’re doing it right. As a parent who is starting to booster-train for the first time, I feel this confusion first hand.

So let’s start with a little terminology. A booster, or belt-positioning booster, is a car seat that does NOT use a built-in harness, but instead uses the vehicle seat belt to restrain the child. There are products that refer to themselves as a “Harnessed Booster” or “Harness-to-Booster” and we call those types of seats “combination seats” because they combine a forward-facing seat that has a 5-point harness with a booster seat. Those are 2 completely different modes of use. If you are using a combination seat with the 5-point harness for your preschool-age child, that’s perfectly fine. Technically, it’s not a booster (even if that’s what the product name implies) unless you are using it in booster mode without the harness.

Most booster seats (or combination seats used in booster mode) have either a 30 or 40-pound weight minimum, a height minimum and an age minimum of 3 to 4 years, generally speaking. Unlike a harnessed seat, which restrains the child with a built-in 5-point harness, the booster is used to literally boost the child up so that the adult seat belt fits properly on the strongest parts of their body – the pelvic bones and collar bone. A good belt fit means the shoulder belt lays flat across the middle of the collar bone and the lap belt lays across the thighs and off the belly.

Now, I realize I just said that 3-year-olds can use boosters, but I want to stop here and clarify something. While some boosters do not list a specific age minimum, and others list age 3 or 4 as the minimum, it is my opinion that dedicated booster seats are not appropriate for 3-year-old children. I am currently raising my second 3-year-old and I’ve spent a pretty extensive amount of time around 3-year-olds and let me let you in on a secret: they are not known for excellent decision making. They just aren’t. My first child was probably one of the most compliant and calm 3-year-olds and even he lacked the frontal lobe development to make the kind of choices that a booster requires a child to make. Putting your 3-year-old in a booster might be legal in some states and with certain products, but it’s not a great idea unless you don’t have any other options.

I put my current 3-year-old child in a booster for less than 2 minutes to take a picture of him and I told him to sit still. This is a progression of what took place in those 2 minutes and it perfectly illustrates the issue:

   

Here’s the thing: boosters require maturity in a way that a 5-point harness doesn’t. A 5-point harness holds your child in the safest position without any effort on your child’s part. In a 5-point harness, your child can fall asleep, can reach for something next to them, can do any number of attempted gymnastics and assuming you have installed the seat well and buckled them correctly, they will still be just as safe. A booster, on the other hand, allows the child a lot of freedom of movement. It allows slouching, it allows toppling over when asleep, it allows them to tuck the shoulder belt behind them and it allows them to lean forward to pick toys off the floor, all the things my 3-year-old did in a matter of 2 minutes. But unlike in a harness, all of these scenarios in a booster are seriously dangerous. A booster only works to keep your child safe in a crash when the seatbelt is positioned properly on the child. So, if you can’t trust your child to sit upright for an entire car ride, even when asleep, they shouldn’t be in a booster. Period.

You can safely keep your child in a 5-point harness until they outgrow it by height or by weight, so there’s not a rush, no matter what anyone else is telling you. There’s no evidence (trust me, I’ve looked for it), that keeping a 6 or 7-year-old in a harness (if they still fit) is more dangerous than using a booster. We do know that allowing a young child who lacks impulse control to move to a booster too soon can absolutely be extremely dangerous.

So, you asked when you should you move your child to a booster and the simplest answer is:

In order to ride in a booster, a child must meet the height, weight AND age minimums of their seat AND they must be able to sit upright through an entire car ride with a good belt fit. Provided that your child is still within the height and weight limits of their harnessed seat, keeping a child in a 5-point harness beyond age 4 or 5 is fine and many parents choose to do that. If your child does not have the impulse control to sit safely in a booster seat but they’ve outgrown all the harnessed seat options, there are medical car seats that will allow your child to remain seated safely for longer (see your physician, medical therapists or a CPST near you for more information).

  

Some other information on boosters can be found here:

IIHS Booster Seat Ratings Bonanza: Where does your booster seat rank?

CarseatBlog recommended high back booster seats

CarseatBlog recommended combination seats

Nuna PIPA Lite Infant Carseat Review: A Master Class in Function

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2018 Nuna PIPA lite and PIPA lite lx Review

I think one of the biggest challenges for a car seat company is when they already have an exceptional product on the market. Typically, it’s not that difficult to find ways to improve your existing product. But when you already have a great seat, like say, the Nuna PIPA, it’s tough to find ways to make it better. Nuna seems to have been working hard on this and for a great majority of families, I think they’ve knocked it out of the park.

First, I’d strongly recommend you read our original Nuna PIPA review because the PIPA lite is, at the most basic level, a PIPA, and that review is a very thorough look at it. I’m not going to waste words retelling the PIPA story because I want to highlight the features of the “lite” model.

The Nuna PIPA lite and PIPA lite lx have the same exceptional base, the same stroller adaptivity, and basically the same dimensions. If you looked at one from a distance, you might not notice it wasn’t an original model PIPA. But when you get closer and especially when you get your hands on it, you can see the ways they’ve taken an already outstanding rear-facing-only seat and thoughtfully upgraded it.

PIPA lite Specs & Features

  • 4-32 pounds; 32” or less AND at least 1” of shell above baby’s head
  • 3 harness height positions, 1 crotch buckle position
  • PIPA base with rigid lower LATCH connectors, seatbelt lockoff AND “stability leg” (otherwise known as a load leg)
  • Energy-absorbing EPP foam through entire top and back of shell
  • FAA-approved for use in an airplane WITH the base
  • 7-year expiration
  • Luxe leatherette carry handle
  • Weight of carrier is only 6.7 pounds including infant insert and canopy
  • The entire seat, foam, fabric, and inserts are flame resistant but contain zero chemical flame retardants
  • Infant insert is now 2 separate pieces
  • 2 sets of inserts/strap covers, one of which is certified organic cotton. The head support insert contains tailor tech memory foam to make it fit and grow with baby.

PIPA lite Measurements

  • Harness slot heights: 6”, 8”, 10”
  • Lowest harness slot height with infant insert and low-birthweight pillow: approximately 4”, the curved nature of the insert makes it tough to measure precisely, but it’s looooow.
  • Crotch strap/buckle position (without insert): 6”
  • Widest point (at the outside of the carrying handle adjuster): 17”
  • Internal shell height: 19”
  • Carrier weight: 6.7 pounds with canopy and inserts (5.3 pounds without)

What Makes it Lite?

So the base is the same, the shell is essentially the same and you might be tempted to dismiss the PIPA lite as nothing new, but you’d be wrong because there are some substantial differences between the original PIPA and the PIPA lite and these differences are big deals.

PIPA lite on left, original PIPA on right

The original PIPA model weighs in at a very reasonable 9.4 pounds, but the PIPA lite (without the inserts) is only 5.3 pounds, making it the lightest rear-facing-only car seat out there. When the seat is empty, it’s almost unbelievably light for an infant seat, especially for such a solid seat made of quality materials. It’s so light you can literally carry it with a single finger. Once you put a baby in it, it’s not quite as light, but I will tell you, without hesitation, the difference in weight between my 4-month-old baby in the PIPA and in the PIPA lite is noticeable. Those 4 pounds make a difference.

I routinely have to carry several handfuls of kid paraphernalia out of the car in addition to the baby, and the PIPA lite is so much easier to carry than other infant seats. I often carry it with 2 fingers or hook it in the crook of my arm and even with Ben in it, it’s generally not the heaviest item in my arms. You might be tempted to dismiss the weight reduction as insignificant, but you would be wrong. I really mean that.

To make the PIPA lite so light, the folks at Nuna had to trim some “fat” from the original PIPA and adjust some of the materials.

What’s missing from the original PIPA?