Safety 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?

Ford Recalls Fusion and Lincoln MKZ Models Over Faulty Steering Wheel

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The Ford Motor Company is recalling 1.3 million Ford Fusion and Lincoln MKZ vehicles because the steering wheel can come loose and can potentially fall off while being driven.

The recall applies to certain Fusion and MKZ vehicles from the 2014-2018 model years:

  • 2014-2017 Ford Fusion vehicles built at the Flat Rock Assembly plant from August 6, 2013 to February 29, 2016
  • 2014-2018 Ford Fusion vehicles built at the Hermosillo Assembly Plant from July 25, 2013 to March 5, 2018
  • 2014-2018 Lincoln MKZ vehicles built at the Hermosillo Assembly Plant from July 25, 2013 to March 5, 2018

The location and date of manufacture can be found on a sticker inside the driver’s door frame.

The cause of the recall is a potentially loose bolt in the steering column. Dealers will replace the existing bolt with a more secure one. According to news reports, the company is aware of at least two collisions and at least one injury resulting from this problem.

Ford’s recall notice can be found here.

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

Takata Airbag Recall: Get Your Car Fixed NOW!

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An attempt to save money takes lives and ultimately costs millions in fines. Are you flipping mad yet? You should be. Updated January 19, 2018

Takata logoIn the largest auto recall in history, tens of millions of vehicles have been recalled to have 28.8 million airbags replaced. Takata airbag inflators have injured more than 100 people and killed 16 people: 12 in the U.S. and 4 in Malaysia, with the most recent being a 50 year old California woman on September 30, 2016. The woman was driving a 2001 Honda Civic and, according to Honda, several recall notices had been sent to the registered owners though the woman had bought the car at the end of 2015.

This story has been in the news for years and you’ve probably paid some attention to it just because of its frequency on the news, but with the media’s fixation on the election, disease du jour, ISIS, and so on, a few airbag deaths get left behind in our daily news consumption of dread.

What’s been happening is that the airbag itself isn’t killing drivers: it’s shrapnel from the explosive device used to deploy the airbag. These metal fragments explode out at such a force that they slice right through skin, eyes, arteries, and even spinal columns. This is happening when the airbags deploy in minor crashes, collisions from which the victims should be walking away.

Before you run out and disconnect your airbags (and I know some of you will), these explosive devices, or inflators, are needed in order to deploy the airbag. In fact, they’re in other safety devices throughout your vehicle and activate in crashes, but we’re focusing on airbags here. When the airbag sensors detect a crash, the inflators ignite, starting a chemical reaction that fills the airbag with gas. It sounds crazy scary, but airbags have saved thousands of lives. Between 2010 and 2013 (the latest year from which we have data), 9,554 lives were saved by frontal airbags. Many thousands upon thousands more lives have been saved since the frontal airbag was introduced in the ‘70s.

Background

Problems with exploding airbags initially cropped up back in 2004 in Alabama when a Honda Accord airbag exploded, injuring its driver. Because it was the first incident, both Honda and Takata chalked it up to being an anomaly and moved on without issuing a recall. According to the New York Times, Honda did report the incident to NHTSA, but didn’t elaborate in the report that it was an airbag rupture. Then again in 2007, three more ruptures were reported to Honda, and again, Honda did not elaborate in their reports to NHTSA that the airbags were exploding. In 2007, Honda told Takata of the ruptures and Takata went to work to find the cause: manufacturing problems at their Mexican plant. However, the ruptures continued and after more testing, Takata linked the problem to manufacturing problems at their Washington state factory.

Recalls began in 2008 and initially only driver’s side airbag inflators were recalled, but passenger airbag inflators were added as those started to rupture as well. Then in August 2015, side airbag inflators came under inspection when a Volkswagen Tiguan’s seat mounted side airbags ruptured after a collision with a deer. GM also reported a rupture to NHTSA. This “SSI-20” inflator is found in Volkswagen and GM vehicles and has been recalled in those vehicles too.

Takata Timeline

The recalled Takata inflator assemblies use a propellant made of ammonium nitrate, which is susceptible to long-term heat and humidity. Takata is the only airbag manufacturer to use ammonium nitrate, an inexpensive chemical. According to a New York Times article, engineers within the company even expressed concern to management about using it. Ammonium nitrate is compressed into small tablets similar in size to baby aspirin, or into wafers. It becomes unstable when it absorbs moisture from the atmosphere and when temperatures vary from day to night, which any vehicle owner knows can happen to a vehicle left outside in the sun. Other manufacturers use guanidine nitrate, a more expensive but stable propellant, and Takata has followed suit for its new inflators.

The obvious solution to the exploding inflators problem is to not use ammonium nitrate, but since it’s such a major component of Takata design, it can’t be completely eliminated right away. Other airbag manufacturers, such as Autoliv, TRW, and Daicel, are helping supply fixes, but since their designs are different than the Takata design, their replacement inflators must be specially fitted to work. In the meantime, Takata has incorporated a desiccant to absorb extra moisture to make it less likely a rupture will occur. We find desiccant packets in everything from pill bottles to shoe boxes to purses, but will this simple fix work in an airbag? The next testing step for the ITC is to see if the desiccant is helpful. NHTSA has given Takata until the end of 2019 to prove it’s safe; it’s not allowed to use ammonium nitrate on new orders, but it can to fill existing orders. This leads to an interesting question: what is an existing order? Is a new model year vehicle an existing order or a new order? Can Takata continue to place ammonium nitrate inflators in new vehicles simply because it fulfills an outstanding order that was placed years ago?

Vehicle manufacturers can take some responsibility in the matter and some have. Honda, which owns a minority stake in Takata, stopped using Takata airbags in its vehicles in late 2015. All but one of the deaths so far have been in Honda vehicles; a man from Georgia died in December 2015 in a 2006 Ford Ranger. Nissan, Ford, Mazda, and Toyota have also fired Takata as a supplier of airbag inflators in their new model vehicles, following Honda’s lead.

What Is the Connection to Child Passengers?

Scott Yon, Chief of the Vehicle Integrity Division in the Office of Defects Investigations at NHTSA, hinted that they’re at little risk of injury because they’re not driving. Passenger side inflator ruptures have injured, but not killed, so far. This is because the passenger side inflator is buried inside the dashboard housing and deploys in an upward motion first, then toward the passenger. However, since there have been injuries recorded, this is another incentive, a very strong one indeed, to keep children in the back seat.

When asked if any shrapnel was found in the back seat, where children under 13 should be sitting at all times in proper restraints for their size and age, NHTSA replied that none was seen. NHTSA also stated that there was no evidence of shrapnel in the roof liners of vehicles where inflators had exploded, which indicates that all damage remained in the front seats. That doesn’t mean that it will always be that way, though, since inflators for side curtain airbags can be found at the A pillar, in the roof line, or at the C pillar, behind the back seat.

Inflator locations

Why

When answers weren’t forthcoming as to why these inflators were exploding, a group of 10 automakers calling themselves the Independent Testing Coalition (ITC), led by former NHTSA Administrator David Kelly, hired Orbital ATK, a rocket science and defense company, to run independent tests and found that failure of the airbags is likely due to a combination of the use of ammonium nitrate as a propellant, the construction of the inflator assembly, and the long-term exposure to humidity and heat found in many southern states. The ITC consists of Honda, Toyota, Nissan, Subaru, Mitsubishi, Ford, GM, Mazda, Fiat Chrysler, and BMW, and formed in 2015 when it became clear that their vehicles would be affected by the recalls.

inflator explosion graphic

You know when certain chemicals react to water there’s an awful reaction (e.g., trying to put a grease fire out with water)? What NHTSA also found in its testing was that ammonium nitrate doesn’t age particularly well. So add heat and humidity to an unstable chemical and we’ve got a recipe for disaster.

What does long-term exposure to high heat and humidity mean anyway? In testing the recalled inflators pulled from fixed vehicles, it became obvious to Takata there was a zone in the U.S. where most of these vehicles had spent a significant amount of their time. The southern Gulf Coast states, well-known for high absolute humidity—eastern Texas, Louisiana, Alabama, Mississippi, Florida, and Georgia—had vehicles where the inflators exploded on testing. Interestingly enough, there were inflators tested in other parts of the U.S. that exploded without explanation; that is, until it was discovered that these vehicles had come from a Gulf Coast state. Being in a warm, humid climate for a vacation, or even for a winter isn’t enough for the propellant to break down. Ruptures start happening in the window between 5-10 years, so we’re talking a significant amount of time.Takata rupture map

Recall Priorities

Vehicles manufactured before 2008 have priority for repair in the recall of the inflators because of the aging propellant issue. NHTSA has mandated that these vehicles have their replacements before the end of 2017. It’s not that easy, though. They may get their replacement, but may also need another before it’s all said and done. Because there are so many inflators that need to be replaced posthaste, newly designed parts simply aren’t available; this is called an interim remedy. Rather than allow defective inflators to stay in vehicles, vehicle manufacturers are replacing them with newer versions of the same Takata inflators. This essentially sets the clock back to 0 and gives Takata and other inflator manufacturers time to design a new inflator that won’t react to environmental issues.

Each affected vehicle manufacturer was asked by NHTSA to prioritize its recalled vehicles into four risk groups:

Priority Group 1: Highest risk vehicles, generally the oldest from model year 2008 or older, have spent time in the high absolute humidity region, and have either a recalled driver’s inflator or both recalled driver’s and passenger’s inflator; parts must be on hand for repair by March 31, 2016, and total completion of remedy must be by December 31, 2017
Priority Group 2: Intermediate-high risk vehicles that include all vehicles with recalled driver’s inflators not in Group 1, and vehicles with passenger inflators that have higher rupture frequency and have spent time in the high absolute humidity region; parts must be on hand for repair by September 20, 2016, and total completion of remedy must be by December 31, 2017
Priority Group 3: High risk vehicles, generally outside the high absolute humidity region, with only passenger inflators or those with certain passenger inflators that have a lower risk of rupture; parts must be on hand for repair by December 31, 2016, and total completion of remedy must be by December 31, 2017
Priority Group 4: Vehicles that will require an interim remedy because alternate parts are not available. Risk of rupture is very low in the years following the fix.

However, NHTSA is concerned about 2 types of owners in response to the interim remedy: the type who will wait years with a dangerous airbag unit until the final fix is available and the type who will get the interim remedy fix and never go back for the final fix. Both would be driving potentially deadly vehicles and what about when they sell or trade-in those vehicles? It then becomes the next potentially unaware owner’s problem. It’s imperative that if a vehicle qualifies for an interim remedy, it should also go back for the final remedy.

Culture of Non-Safety