>Answers to “Mistake Monday” 3/15/10

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(please see bottom of page for teaching points & a printable version of the American Academy of Pediatrics’ tips for positioning newborns and preemies in car seats)

– **The baby’s chin is on his chest**
– There is an aftermarket infant head support used (the white product behind the child’s head)
– Harness straps are too loose
Note: The buckle hardware resting on the infant’s abdomen is not dangerous.


The Baby Stops Breathing!
Unlike our other mistake Mondays, the biggest mistake in this picture – the infant’s chin on his chest – is likely to harm the baby without a crash even occurring.  The recent recall of thousands of infant slings highlighted this same issue – that newborns can stop breathing if their chin rests on their chest.  

Small infants have very short necks, so when the neck flexes the chin falls forward onto the chest and the infant’s own chest presses on the chin.  Until babies are at least a month old, the connection between the jaw (mandible) and the skull bones (temporal bone) is not formed, which means that pressure upwards and backwards on the jaw, as happens when the chin rests on the chest, pushes the jaw backwards.  The tongue sits inside the jaw bone and is pushed into the back of the mouth and onto the soft palate.  The tongue thereby completely blocks the flow of air from the nose into the lower parts of the airway.  Babies ONLY breathe through their nose (except when crying and gasping).  Babies can not switch and breathe through their mouth as older kids and adults can – so if the flow of air is blocked between the nose and the lower airway, the baby will stop breathing.

The ironic part is that U-shaped infant head supports, which by the way have no safety regulations or crash testing that they must conform to, actually make matters worse.  Head supports, like the one in the picture, which try to prevent the infant’s head from turning to the side often make matters worse.  The back of an infant’s head (occiput) is very prominent.  Forcing the head to rest straight forward, as these infant head supports try to do by preventing the head from turning to the side, only encourages the head to fall forward and the chin to rest on the chest.  Having the baby’s head turned slightly to the side (but with the chin far above the chest) is a much more natural position for the infant’s large head.


3 Steps to Keeping an Infant’s Head in a Safe Position 
1.  Make sure the harness straps are snug

  •      Snug straps keep the body & head straighter by preventing the baby from slumping over
  •      Some infant seats are too big for preemies & small newborns – check to see if yours is appropriate here

2.  Make sure the car seat is as reclined as the manufacturer allows

  •  For most infant seats, the most reclined the seat can be is so that the part where the infant’s head & back rests makes a 45 degree angle to the ground.   Most seats have a level indicator – be it a bubble level, pendulum gauge, or just a straight line – to help you know how reclined the seat can be when in the vehicle.
  • Image from AAP – showing a rolled towel under the base to help acheive the 45 degree angle

3.   Do NOT place anything behind or in front of the baby’s head & neck

  • Do NOT use an infant head/body positioner that did not come with the car seat.  Such “aftermarket” products are not tested for safety – either in a crash or just general safety – and often make the situation worse by tipping the head forward and changing how the straps fit on the child’s body.  In addition, the use of an “aftermarket” product in a car seat will void the car seat manufacturer’s warranty.  Please see the bottom of this post for more specific information from each car seat manufacturer – along with an easy-to-print handout on the topic.
  • Most infant seats come with removable infant head rests. Of the infant car seats currently on the market with removable head rests, all can be safely removed EXCEPT for the one in the Britax Chaperone (as this one is part of the side impact protection of the seat).  Except for the one in the Britax Chaperone, these infant head rests are NOT safety features of the seat – so if you think that the head rest is either not improving, or worsening, the infant’s head position we would recommend removing it. 
  • If you do not like how it looks with the baby’s head turned to the side, you can roll two small diaper cloths and place them alongside the baby’s head.
The American Academy of Pediatrics issued an updated Clinical Report on Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge – which has great tips for positioning newborns of all sizes in car seats.

Bull MJ.  Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge. Pediatrics. 2009 May 5; 1424-1429.

Tonkin SL. Airway of babies in car seats. The New Zealand Medical Journal. 1998 Sep 25;111(1074): 372

Aftermarket Products: What Do The Car Seat Manufacturers Think of Them??

**For an easy-to-print handout of this information, click here***

Fleece bunting – NOT SAFE for the car seat

You’ve seen them – the infant head inserts, the fleece buntings, the shoulder strap covers – they line several aisles in most Babies R Us. They are made to be used with the car seat – but didn’t come with the car seat.

Did you know that unlike your child’s car seat which must pass rigorous crash testing, these “aftermarket products” have no crash testing or other crash safety standards they must meet? Most parents buy these products thinking they will make the car seat safer and more comfortable for their baby – not realizing that these products usually turn a safe car seat into an unsafe one.

But don’t take our word for it, here is what the car seat manufacturers have to say about aftermarket products. These excerpts were taken directly from the child safety seat instruction manuals.

Baby Trend

o Do Not dress your child in bulky clothing or other garments that will hinder the harness from being snug around your baby and properly latched between your child’s legs.

o Accessory products for use with the Safety Seat are acceptable for use provided that they do not interfere with the harness assembly, or the proper adjustment of the harness such that it remains tight on the child’s shoulders at all times. Thick, soft, or other compressible material in excess of 1/4 inch thick should not be placed behind or under the child or between the child and harness straps. Examples of accessory products are head support pillows or rolled blankets to add additional head support.


o The use of non-Britax Child Safety, Inc. covers, inserts, toys, accessories, or tightening devices is not approved by Britax. Their use could cause this restraint to fail Federal Safety Standards or perform worse in a crash. Their use automatically voids the Britax warranty.


o NEVER use clothing or blankets that interfere with fastening or tightening the harness. An unsecured child could be ejected in a sudden stop or crash! To keep child warm, place a blanket over child and restraint AFTER you have properly secured child in harness.

o DO NOT use any accessories, pads or products supplied by other manufacturers with this Child Restraint. Items not tested with this restraint could injure your child.

Dorel (Maxi Cosi, Cosco, Eddie Bauer, Safety 1st):

o Dorel Juvenile Group does not recommend the use of any child restraint accessories except those recommended by DJG.


o In cold weather, DO NOT dress the child in bulky clothing like snowsuits if the child is riding in a child restraint. Bulky coats/ snowsuits make it difficult to properly tighten the harness to the child, which may allow the child to be ejected from the restraint during a crash.


o DO NOT use accessories or parts other than those provided by Graco. Their use could alter the performance of the car seat.


o Do not modify your Infant Car Seat or Base. Only use products and accessories approved by Orbit Baby to ensure the safety of your child. This limited warranty does not apply to: defects resulting from use with covers, inserts, accessories, tightening devices, or other components not supplied by or expressly approved in writing by Orbit Baby.

Peg Perego

o Use only approved parts. Use of unapproved parts can affect the safety of the car seat and cause serious injuries in an accident.

Sunshine Kids

o ´╗┐Using any non-Sunshine Kids product with this restraint; or any product not specifically approved by Sunshine Kids for use with this restraint is not allowed. Use of such products voids manufacturer’s warranty and may seriously impact the products ability to perform properly in an accident.

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