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Carseats and Torticollis

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When I’m not carseating, I work as a physical therapist in a pediatric setting. As you can imagine, there tends to be a lot of overlap with carseats and my “real” job, but you might be surprised to hear that the most common intersection of the two has to do with babies who are born with a tight neck muscle.

Torticollis is a condition where a muscle in one side of the neck gets tight, usually because of the position of the baby in utero. Torticollis tends to cause babies to have a strong preference for rotating the neck in one direction and tilting the head in the other direction. It’s most common in first babies, twins and babies of petite mothers (all because of space constraints in utero). One of the biggest issues that results from torticollis is that babies can end up with an asymmetrically flat head, known as plagiocephaly. For some kids this is mild and it improves on its own; for others, they may require a specially made and adjusted helmet to help the head round out.

In virtually every evaluation for a baby with torticollis and plagiocephaly, parents (understandably) express concern about what, if anything, they can do in the carseat to keep their baby’s head from tilting or rotating. And sometimes they’ve already tried things- usually aftermarket inserts, sometimes wash cloths, when the secret is, you probably don’t need to add anything.

As we know, adding anything to a carseat that didn’t come with the seat (or was not expressly crash tested with the seat and approved by the carseat manufacturer), is generally not a good idea. It will void the carseat warranty, it goes against every manual (which, in most states makes it illegal) and it may potentially result in injury in a crash. So, basically what I’m saying is, even if you’re worried about your baby’s head shape, please don’t put aftermarket products in the carseat. They won’t help much and they may put your child at increased risk.

Truthfully, unless your baby spends hours, like, literal sustained hours each day in a carseat, the seat isn’t really what is causing the flatness to develop. So fear not, the carseat is just fine the way it is. I know that at times seeing baby’s head tilted or rotated in the car can be troubling. But rest assured that a tilt to the side or rotation isn’t unsafe. The only position that is worrisome is if baby’s chin tips down onto its chest, which in small infants can compromise the airway (and is probably a sign that your child’s carseat isn’t reclined enough- find a CPST in your area to have it checked out!).

blanketsIf you’re worried about baby’s head falling to the side, you can try rolled up receiving blankets on either side of baby, placed after baby is buckled. I will be honest that I don’t necessarily love this set up because baby could rotate their head and spend a sustained amount of time with their face in a blanket, but it is a parental decision and if you feel strongly that something needs to be done to keep baby’s head in midline, this is your safest option.

If you want to make sure that baby rotates their head to their non-preferred side, you can definitely make that happen in the carseat. If your seat allows it, and several explicitly don’t, so consult your manual, you can hang a soft toy (like, literally made of a material and so soft you would throw it directly at your child’s head and they wouldn’t be injured) from the handle, offset towards the side you want baby to look. I had one creative parent who tied a few ribbons on the non-preferred side of the handle. They presented no risk to baby, but were bright and got baby to rotate his head that way. Other options include, if you have another backseat passenger that baby will like to look at, seat that person on baby’s non-preferred side. Or if baby is not sitting in the middle seat, and you can get a good installation and feel comfortable with baby outboard, place their seat so that they have to look towards their non-preferred side to see out the nearest window.

Most of all, any baby, but especially a baby with torticollis, will benefit from the least possible amount of awake time in any baby device that puts pressure on baby’s head like a swing, bouncy seat, cradle or carseat. Babies need a lot of floor time when they’re awake so they have room to learn to roll and sit and crawl and they especially need time on their tummy to strengthen their necks, which will help correct torticollis.

If you think your baby may have torticollis or plagiocephaly, talk to your pediatrician about it and see if a referral to a physical therapist in your area might be appropriate. And if you’re worried about carseat positioning with a baby with torticollis and/or plagiocephaly, find a CPST near you to check your set up and see if there’s anything else that can be done to keep baby safe and keep baby’s head nice and round.

Cheap Portable Carseats: Don’t Believe the Hype

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A few years ago we brought you a “review” of an illegal foreign car seat to explain why people shouldn’t buy them. Seats like these would pop up now and then but were mostly off our radar for a long time…until recently. In the past few weeks, we’ve seen dozens of references to them, so we felt it was time for another post, this time debunking many of the claims and explaining the various ways these seats do not meet federal safety regulations.

What is it?

One problem in determining exactly what’s wrong with these seats is that there are so many different versions of them, each with slightly different descriptions. It’s also impossible to actually contact a manufacturer to ask questions because no manufacturer information is listed anywhere (which is, in itself, a violation of U.S. standards…but we’ll get to that in a minute).

First, we need to determine what category of child restraint these things are. They’re marketed as a harnessed car seat: Attach the restraint to your seat, buckle in your kid, and go! The thing is, harnessed child restraints are required to be installed with either a seatbelt or with LATCH. This “restraint” doesn’t include lower anchor straps or a tether strap, and it’s “installed” with some straps and rings, not with a seatbelt at all. So if it is, indeed, meant to act as a 5-point child restraint, it’s automatically out of compliance because it doesn’t install with LATCH or a seatbelt.

Sometimes the listings and/or paltry instructions that come with the seats also say that you also should/must buckle the seatbelt around the child. In that case, the seat is actually functioning like a booster seat or a wearable harness, both of which have their own requirements that these products do not meet.

Since inconsistencies keep us from actually determining what the heck these things even are, let’s explore some other issues.

Either Way, There are Problems

From a regulatory standpoint, it matters whether this thing is meant to be used with a seatbelt or not. From a practical standpoint, there are problems either way.

This crash test, which we shared in our other review, shows what happens when the seat is used without a seatbelt:

I don’t have a crash test of the seat used with the seatbelt, but I do have a video showing the likely issues this seat has in restraining a child, with or without one:

Placement in the car

What the ads won’t tell you—but the “instructions” might—

Why Rear-Facing Is Better: Your RF Link Guide

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Evidence-based justification for extended rear-facing

It’s all the rage among parents nowadays: extended rear-facing. If you’re turning your child to face forward before age 2, then you’re old-schooling it and increasing your child’s risk of injury in a crash. Many pediatricians still hold onto the now ancient recommendation of turning kids forward-facing at age 1 and 20 lbs., even though their own professional organization, the American Academy of Pediatrics, hasn’t recommended that since before 2002. You were probably in grade school then.

Why is it so critical for kids to stay rear-facing?

When you use the carseat right, it protects them and you from potentially being forever changed if you get into a crash.

Simple Physics Lesson

A carseat will always move toward the point of impact (Newton’s 1st Law). In a frontal collision—statistically the most common type of severe/fatal crash—the entire back of a rear-facing carseat will protect the head, neck, and spine of a child as it rotates down toward the front of the vehicle. Even in a side impact, which is a more serious type of crash due to its proximity to passengers, there is usually an element of frontal movement, such as a vehicle moving forward through an intersection, as it’s hit from the side. So a rear-facing carseat will rotate down and forward, then toward the side where the impact occurs.

Click each graphic to see the motion:

rf-physics-animation ff-physics-animation

Compare this to a forward-facing child in a harnessed carseat. In a frontal crash, the carseat still rotates down and forward toward the front of the vehicle, and the child will be flung forward into the harness and forward of the carseat shell. In a side impact, again the carseat rotates down and forward toward the front of the vehicle; the child comes forward into the harness and out of the carseat shell and there is rotation toward the vehicle door where the impact occurs. Because the harness is holding only the shoulders and hips, the head, arms, and legs are flung violently forward. If the harness is loose, which is one of the most common mistakes a caregiver makes, there’s a high likelihood of the child hitting the vehicle seat in front or the side pillar. According to this study, rear-facing children 12-23 months are 5.53 times safer in a side impact than forward-facing children and there’s no indication that safety magically disappears at 24 months.

Anatomy 101

The folklore is that a child’s neck muscles aren’t developed enough to keep a baby’s neck safe in a car crash, which is why they have to face the rear of the vehicle. I suppose that’s true in a way: it does take babies time to develop their musculature so they can hold their heads up to keep their airways open. But the muscles don’t protect the fragile spinal cord, which is the bundle of nerve fibers that forms the central nervous system and is connected to the brainstem. No amount of baby push-ups will strengthen your child’s muscles to the point of protecting his spinal cord.

The bones of the spinal column are what actually protect the spinal cord and in infants and young children; they aren’t completely fused together for years. One of the most important cervical bones, the Atlas (C1), is what attaches the head to the spinal column. Drawings show where it ossifies, or fuses, at varying times: the anterior arch fuses around age 7, while the posterior neural arches fuse around age 3. Before it fuses, the Atlas and Axis (C2), the 2nd vertebra that the Atlas nestles into, are made of bone and cartilage, which is very pliable. These two vertebrae are held in place by ligaments, which are very elastic (lax) to allow the child to grow.

atlas-side-view axis-side-view simplified-upper-cervical-spine

Studies of infant cadavers have shown that vertebral columns can stretch up to 2” but that the spinal cord is damaged after only ¼”. Given that a baby’s head accounts for ¼ of its total body size versus 1/7 an adult’s size, plus the immaturity of its vertebrae and laxity of the ligaments holding those vertebrae together, rear-facing seems the obvious choice.

The child’s large head shifts the fulcrum of movement, where the head swings forward, higher, elongating the spinal column and potentially causing catastrophic damage to the spinal cord. Before age 8, this fulcrum is in the upper cervical spine, at C2-C3. After age 8, the fulcrum shifts down to C5-C6, where it stays into adulthood. When you hear the term “internal decapitation,” it encompasses this movement of the upper cervical spine since the head swinging forward must happen in order for the ligaments to stretch and pull the head from the Atlas.

Another devastating injury that doesn’t show up on x-ray is called Spinal Cord Injury without Radiographic Abnormality (SCIWORA). This is when the spinal cord stretches because of the elasticity of the ligaments and cartilage in the spinal column. An x-ray will show normal bone alignment and no fractures, but the spinal cord may be irreversibly damaged. Remember that this bundle of fibers can only stretch up to ¼” before having catastrophic damage.

The evidence is clear. Rear-facing carseats protect the most fragile part of a developing child’s body: the head and spinal column. The American Academy of Pediatrics recommends rear-facing to a minimum of age 2 and instructs their pediatricians to counsel parents about rear-facing to age 2 and longer as the carseat allows. The National Highway Traffic Safety Administration (NHTSA) recommends rear-facing  as long as possible.

Favorite Links

The American Academy of Pediatrics (AAP) has recommended since 2002 that after age 1 and 20 lbs., children should ride in a rear-facing convertible seat until reaching the weight limit of that carseat. They amended that policy in March 2011 to recommend rear-facing to age 2 or until they reach the “highest weight or height allowed” by that convertible carseat.

 

Note how the legs fly away from the back of the vehicle seat during the test. In the forward-facing seat, the properly secured dummy bends nearly in half during the crash test. Photo courtesy Kathy Weber, ret., UMTRI, and SafetyBeltSafe USA.

Note how the legs fly away from the back of the vehicle seat during the rear-facing test on the left. In the forward-facing seat, the properly secured dummy bends nearly in half during the crash test.  Photo courtesy Kathy Weber, ret., UMTRI, and SafetyBeltSafe USA.

Forward-facing children under the age of 2 are 75% more likely to be injured.  (Car Safety Seats for Children: Rear Facing for Best Protection

Here’s an article showing why children up to the age of 2 are more than 5 times safer riding rear-facing.  (Rear-Facing Car Safety Seats Getting the Message Right)

SafetyBeltSafe USA’s opinion on how long children should ride rear-facing. (How Long Should Children Ride Facing the Back of the Car?)

After reviewing studies from the U.S. and Sweden, a study published in the highly regarded British Medical Journal advises keeping children rear-facing until age 4.  (www.bmj.com/cgi/content/full/338/jun11_2/b1994?view=long&pmid=19520728)

Leg injuries account for 28% of significant injuries faced by forward-facing children in crashes  (Jermakian, J.S., et al. “Lower Extremity Injuries in Children Seated in Forward Facing Child Restraint Systems.” Traffic Injury Prevention 8 (2007): 171-179.)

This analysis shows how leg injuries are common among forward-facing children (Bennett, T.D., et al. “Crash Analysis of Lower Extremity Injuries in Children Restrained in Forward-facing Car Seats During Front and Rear Impacts.” Journal of TRAUMA® Injury, Infection, and Critical Care 2006;61:592-597

A tightly installed rear-facing carseat allows the vehicle and carseat to absorb crash forces and increases “ride down,” the amount of time it takes a body to come to a stop in a crash.  The longer the ride down time, the less chance of injury.  (http://www.car-safety.org/rearface.html)

Rear-facing carseats provide excellent protection in side impacts as well.  Because there’s usually a vehicle moving forward, as through an intersection, that element of forward motion can easily throw a child’s head clear of the carseat if he’s forward-facing.  If rear-facing, his head will stay protected inside the carseat.  (http://www.carseatsite.com/rf.htm)

Infants and young toddlers have spines made of soft bone and cartilage that doesn’t begin to harden until around age 3.  As a result, the spinal column can stretch up to 2 inches; however, the spinal cord will rupture after being stretched after only ¼ inch.  This damage cannot be repaired.  (http://www.carseat.org/Technical/tech_update.htm#rearfacFF)

Evenflo is now requiring that children be age 2 before forward-facing in their convertible and combination carseats.
 

Approximately 75% of kids in Sweden rear-face until at least age 4.  From 1999-2006, only 4 rear-facing children under age 4 were killed in crashes and their deaths were due to circumstances unrelated to the direction the carseat was facing (fire, drowning, excessive intrusion).  During that same timeframe, 6 kids under age 4 facing forward in booster seats were killed; 3 of these crashes were potentially survivable crashes had the children been in rear-facing carseats.  (http://www.bmj.com/cgi/content/full/338/jun11_2/b1994)

Anecdotal evidence suggests that infants around ages 10 mos.-18 mos. enter a fussy stage that makes it difficult to put them into any carseat, rear- or forward-facing.  Many parents prematurely switch the rear-facing carseat forward-facing thinking that the child is objecting to riding rear-facing, when the child is objecting to being restrained at all.  Visit the Car Seat Safety forums at www.car-seat.org and you’ll hear from other experienced parents regarding this phase.

The above video shows how the dummy stays contained in the seat during a rear-facing crash test.  The tape on the dummy’s head is for measurement and doesn’t affect its head during the test.

This video is the companion video to the one above and shows a side view of the crash test.  Note how little the head moves.

The above video shows a properly installed forward-facing seat.  Note the seat belt stretch and how far forward the dummy bends.

The above video from Norway shows the differences between rear- and forward-facing carseats in an animated crash.

The above video from the Buckle Up Brutus at Ohio State University demonstrates the difference between rear-facing and forward-facing in crash tests.

If you need more convincing, take it from Dr. Marilyn Bull, a noted pediatrician from one of the country’s best pediatric hospitals, Riley Children’s Hospital in Indiana. This video was produced for, and used in, the current Child Passenger Safety Technician course.

Vehicle crashes are the number 1 killer of children.  Protect your children to the best of your ability.  Follow best practice.

Graco 4Ever Extend2Fit All-in-One: Rear-Facing Space Comparison

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One of our most popular blogs is the Rear-Facing Space Comparison where we rate convertible seats based on the amount of room they take up in my vehicle compared with other seats in the group.

I was eager to add the new Graco 4Ever Extend2Fit to the comparison but I knew this was going to be more work than usual based on the many rear-facing installation options you have with this particular seat. This seat has 4 recline positions on the base that can be used to achieve an acceptable rear-facing recline position as per the angle indicator. The angle indicator is a liquid bubble level that has to be in the range of the blue line shown on the window. 4Ever Extend2Fit also has Graco’s unique 4-position legrest extension feature (truthfully there are 3 extension positions, the first position is fully retracted) AND the coveted 50 pound rear-facing weight limit.

 

I summarized my findings in the space comparison ratings but I wanted to supplement that information with the full scope of my conclusions here.

I started with the 4Ever Extend2Fit in base position #1 (most reclined), no legrest extension, head rest flush with shell. This is how the seat would be installed for a newborn or younger baby. I gained 3.5″ of room (based on the worst performing seat in the peer group). This measurement translates into a “B” rating in the comparison.

 

 

Base position #2 (more upright), no legrest extension, head rest flush with shell. This is how the seat might be installed for an older baby who has good head and neck control and can tolerate being seated in a more upright position. In this position I gained 4″ of room. This is a B+ rating in the comparison.

 

 

Base position #3 (very upright), no legrest extension, head rest fully extended. In this position the bubble level was outside of the acceptable range for rear-facing. This was NOT an acceptable installation as per the angle indicator so I’m not counting it. However, for those who are curious, it only gave me an extra half inch of room beyond what I got with the base in position #2. My measurement with the seat in this position was +4.5″ of space.

 

 

At this point, it seemed likely to me that you would only be able to use 2 of the 4 base positions in any particular vehicle to achieve an acceptable recline angle in the range allowed. But as I found out when I started to install using the legrest extension, the recline angle can change when you start to use this feature. More on that in a little while.

I went back to base position #2, extended the legrest 1 notch, head rest is still fully extended. Because I’m using the legrest extension now, I’m starting to lose space. Now I have +3.5″ (which is what I had with the seat fully reclined reclined in position #1 and no legrest extension). Again, this rates a “B” in the comparison.

 

Here we are in the same #2 base position, with the legrest fully extended and the head rest fully extended. As you can see, it’s taking up a LOT of space now. At this point I’m measuring a gain of only 1″ (based on the biggest space hogs in the peer group). In the comparison, this is a C- rating.

However, I was surprised to see the bubble level indicator in the middle of the blue line range now. When I installed using the same #2 base position without using the legrest extension, the bubble was much closer to the end of the allowable range. This made me wonder if I could get an acceptable installation using recline position #3 on the base with the legrest panel fully extended…

 

 

Final installation: Base position #3, legrest fully extended, head rest fully extended.  The liquid bubble is on the most upright end of acceptable range but it is within the range. I picked up a extra half inch of space with the base in position #3. The measurement is now +1.5″ which is a little better but still rates a C- in the comparison.

 

The other thing to keep your eye on when using the legrest extension feature is the amount of overhang allowed. When you start extending the legrest panel you increase the space between carseat and the vehicle seat and that positions the base closer to the edge of the vehicle seat cushion. Thankfully, Graco put a little blue sticker label on the edge of the base to show what the acceptable amount of overhang is. Overhang past that blue line is NOT acceptable. Too much overhang could be an issue in backseats with shallow cushions (e.g., Jeep Wranglers, some compact cars, extended cab pickup trucks, etc.). Luckily, you don’t have to use the legrest extension so you can just ignore that option if overhang becomes an issue.

 

Summary:

The Graco 4Ever Extend2Fit is a versatile 4-in-1 product with a 50 lbs. rear-facing weight limit and a very unique legrest extension feature. You may use base positions 1, 2, 3 or 4 to achieve an appropriate RF recline angle as per the angle indicator but don’t expect that all 4 positions will yield an appropriate recline position in your vehicle. You may use any of the legrest panel positions rear-facing without restriction. The only rules are: make sure your recline angle is in the allowable range and make sure you don’t have too much overhang of the base.

Having so many rear-facing installation options creates more potential for finding a suitable recline angle, giving your child some extra legroom and taking up less space in your vehicle. However, the reality is that once you start using the legrest extension feature, the seat definitely takes up more front-to-back space in the vehicle. I lost 2-3″ of space in my vehicle when I extended the legrest fully and that was using the more upright #2 & #3 recline positions. The seat would have taken up even more room if I had extended the legrest in the most reclined position.

Parents who are taller than average and/or driving vehicles with limited legroom in the backseat may find that they aren’t able to take advantage of the legrest extension feature without seriously compromising the space upfront for the driver or passenger. I found it interesting that in my vehicle the less expensive Graco Extend2Fit convertible actually takes up slightly less space without the legrest extension than the 4Ever Extend2Fit model. With the legrest fully extended, both seats had the same +1.5″ measurement.

Regular Extend2Fit convertible on left; 4Ever Extend2Fit on right

 

 

 

If front-to-back space is a big issue in your vehicle, and you don’t think that you will ever be able to take advantage of the legrest extension, then you might be better off with a different convertible seat since it doesn’t make sense to pay for a feature you won’t ever use. The original Graco 4Ever All-in-One, Graco Milestone All-in-One, Graco MySize 65 convertible & Graco Contender 65 convertible are all options that did better than average in our Rear-Facing Space Comparison but don’t have the Extend2Fit legrest feature.