Resources Archive

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?

Calculating the Cost of Saving Lives

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The Centers for Disease Control and Prevention has recently released a new version of a tool to help people (legislators, law enforcement officials, advocates, etc.) determine what kind of impact various motor vehicle laws and enforcement practices would have on saving lives, and what the overall cost/savings would be.  The tool is called the Motor Vehicle Prioritizing Interventions and Cost Calculator for States—but you can call it MV PICCS (pronounced “picks”) for short.

When you first open the calculator, you see a map of the United States with each state color-coded according to its 2015 vehicle death rate. You can then select a state and select various laws/fines/enforcement options that might reduce motor vehicle fatalities and injuries. You can enter a specific budget, and you can also determine whether to have fees and fines from those interventions rolled back into the cost of implementation.

Then the calculator will show an estimate of how many lives will be saved, how many injuries will be prevented, the cost of enforcement, the fees/fines produced, and the overall cost to the state.

I decided to play around with the calculator a bit. First, I selected my current home: Illinois. Illinois already has a very low vehicle death rate (7.8 per 100,000 people). One thing that really bugs me about Illinois, though, is the lack of a motorcycle helmet law. Of the motorcycles I see on the road, I’d say around 25% have riders with helmets. My small community alone has a few motorcycle deaths each year, and I often wonder how many of those could be prevented with helmets.

So on MV PICCS, I checked the option for motorcycle helmets and the option to use fees and fines to offset costs. I then hit the “run model” button, but I got a message saying that it couldn’t select any interventions given a budget of $0. So I entered a budget of $1,000,000, and it said it couldn’t select any interventions given a budget of $1,000,000.

I decided to keep my $1 million budget, but, in addition to the motorcycle helmet law, I checked “Increased Seat Belt Fine” and “In Person Renewal” (for drivers license renewals of those aged 70 or older). This time it did calculate, and it showed 102 lives saved (42 from helmets, 47 from increased seatbelt fines, and 13 from in-person renewal). The overall cost to the state would be $-3.85 million, meaning the fines and fees would greatly outweigh the implementation costs.

Then I decided to play with Wyoming, the state with the highest vehicle death rate: 24.7 per 100,000 people. For Wyoming, I selected seven interventions (Motorcycle Helmet, License Plate Impoundment, In Person Renewal, Increased Seat Belt Fine, Primary Enforcement Seat Belt Law, Seat Belt Enforcement Campaign, and Sobriety Checkpoints.) I also entered a budget of $1,000,000.

MV PICC calculated 40 lives saved and 2,535 injuries prevented. The overall cost to the state would be $840,000.

(It’s also important to remember that laws and driving practices aren’t the only contributors to vehicle deaths. As we’ve reported before, fatality rates are often higher in rural areas, due in part to increased response time for emergency services. States like Wyoming and Montana could certainly reduce their fatality levels with the enforcement of certain laws, but that won’t change issues like terrain and response times.)

While the calculator was kind of interesting to play around with, and while it might provide a decent cost-benefit analysis for some scenarios, I felt like it was a bit too simplistic. I finally figured out that its estimated cost to Illinois to implement a motorcycle helmet law would be $3.5 million. There would be some additional costs in the first year for sure (to update driver’s handbooks, update websites, publicize the law, update law enforcement), but surely the long-term costs wouldn’t be anywhere near that high. It would be nice to see a 5- or 10-year cost estimate.

I also felt the calculator lacked a lot of important options that play huge roles in motor vehicle deaths. There are no options for enhanced child restraint laws or enforcement. There is no option to lower speed limits. There is no option for implementing/enhancing graduated driver’s license programs for teens. And, perhaps most glaringly, there is no option for enhanced laws or enforcement surrounding distracted driving.

The MV PICCS is a decent starting point, but it’s not all-encompassing. Without having a more comprehensive list of interventions and a longer-term view of costs, I’m not sure how useful the calculator will actually be. For finding quick statistics and getting a general overview, though, I can see how it could be a handy tool.

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

Will Skinny be back in 2018? A plea for more narrow carseats & boosters.

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Discontinued width-adjustable Britax StarRiser/Comfy

Skinny is in high demand – that is, if you’re a carseat or booster. Unfortunately, skinny is also very hard to come by these days and that’s a real problem. In a time when many Americans are downsizing their vehicles –  increased laws and awareness are keeping more kids in carseats and boosters longer. The combination of these two factors is creating a real space problem.

We need more seats that can fit in narrow seating positions and in those tricky 3-across situations. Manufacturers really need to work to address this issue because if I see one more Turbobooster without armrests because they’re trying to make it fit next to another carseat – I’m going to lose my mind!

Suggestions for CR Manufacturers:

Work on designing new, narrow seats, or perhaps booster seats that are width-adjustable and pay particular attention to how your various models fit/puzzle/mesh next to each other.  

Current Options:

For those parents and caregivers who can’t wait for future seats – the Cosco Scenera NEXT is a neat little convertible that is going to work in a lot of tight situations. But it’s very compact and really meant for infants and small toddlers.

The Evenflo Tribute convertible can be a saving grace in many 3-across scenarios too but again, it’s not that big and many kids will outgrow it by height before hitting 40 lbs.

The Safety 1st Guide 65 convertible is narrow and will last longer before being outgrown but some parents wind up dismayed when their child falls asleep and has “head slump” – an issue caused by the tilted headrest.

The Diono Radian models have built their reputation on being narrow and working well in a lot of 3-across scenarios but they have their quirks and incompatibility issues in some cases. Whenever possible, you should “try before you buy”.

I’ve seen the Harmony Defender forward-facing combination seat recommended for people looking for a slim seat but not everyone wants a carseat that has to be assembled like IKEA furniture.

The Graco Tranzitions (aka Graco Wayz) is often recommended for families on a budget who need a slim forward-facing seat but it’s really not that narrow (although it does have a low profile) and it can be incompatible with some seatbelt installations once the child is over the LATCH weight limit.

The brand new Chicco MyFit forward-facing combination seat is being released this month and seems very promising since it’s only 17.5″ wide! We are currently evaluating its abilities and will have a full review posted soon.

The forward-facing only IMMI GO is a narrow option that some parents may want to consider but it’s not a traditional carseat and it lacks solid, side structure and head support. Plus, you really need to install it in a seating position with a full set of LATCH anchors (lower anchors & tether). It requires tethering, installs quickly and easily with lower anchors but is generally incompatible with most seatbelt installations.

Another non-traditional product for kids 3+ who weigh at least 30 lbs. is the Ride Safer Travel Vest. The vest is available in 2 sizes; small (30-60 lbs.) or large (50-80 lbs.). There is an optional tether strap that can be used with either size vest and there is also a narrow backless booster (Delighter) that can be purchased for use with the vest.

Last but not least, the Britax ClickTight Convertibles, the Clek Foonf Clek Fllo are all narrow convertibles but they’re pricey and out of reach for many families on a budget.

In the last two decades, the industry has been very focused on bigger and wider. No doubt this is due to the fact that American kids are getting bigger and wider, not to mention they’re staying in carseats and boosters for much longer than in the past. Plus, there has been a strong, steady demand for higher-weight carseats and boosters that can accommodate bigger/older children. This is all well and good but you can’t focus exclusively on bigger and wider because if the bigger seats don’t fit in smaller vehicles, then what?

What do you think happens when a family of 5 trades in their Tahoe for a Prius? And what happens at a check event when a car pulls in with 3 kids in the back of an old Corolla and all 3 need to be in seats? My CPS program stocks Evenflo Tributesinstitutional models of the Maestro and Harmony Youth Boosters but sometimes it’s not enough and parents are forced to make those “tough choices”. Do you put a kid up front? Let the oldest ride without a booster in back even though he clearly still needs one? This is reality. This is what we’re dealing with at events all across the nation because of space issues.

Manufacturers, you can help those of us in the trenches (and those who are personally in these predicaments) by meeting these challenges and making more 3-across-and-small-vehicle-friendly seats. We also desperately need more affordable options for our CPS programs that work in these tight situations! I know we can’t fix or solve every incompatibility that we encounter but this particular problem seems to have some possible solutions that are realistic and within reach. I hope you’ll agree.