Recent Trends in Infant Car Seat Tolerance Screening Failure Within a Large Health Care System, 2014–2018

Abstract

To describe temporal trends in car seat tolerance screening (CSTS) failure within a large hospital system (2014-2018). METHODS: We conducted a retrospective cohort study using electronic medical record data for infants who underwent a CSTS. Our primary outcome measure was the CSTS failure rate. Covariates included year, CSTS location (well nursery or NICU), gestational age (GA), race, sex, birth weight, CSTS date, and age at CSTS. Associations of covariates with CSTS failure were examined by using x 2 tests, t tests, analysis of variance, and Wilcoxon rank tests. Multivariable logistic regression was used to determine the adjusted odds of CSTS failure. RESULTS: Of 4849 infants tested, the failure rate was 8.1% (n 5 394). Most CSTS occurred in the well nursery (79.5%) and involved late preterm (55.2%) or term infants (23.7%). In bivariate analyses, year, unit location, higher birth weight, younger chronological age at testing, and higher GA were positively associated with CSTS failure (P , .05). After stratification by CSTS location, the CSTS failure rate rose in the well nursery but remained stable in the NICU, and use of screening rose among term infants. In the adjusted model, year, GA, and corrected gestational age at CSTS were associated with failure. Each subsequent year was associated with a 19% increase in odds of CSTS failure (P , .001). CONCLUSIONS: We found a higher rate of CSTS failure in the well nursery compared with the NICU, and the difference in failure rates increased over time. Improved understanding of infants at the highest risk of CSTS failure could impact routine screening guidelines.

Adherence to Car Seat Tolerance Screening Differs by Indication and Patient Characteristics

“…Lower adherence to CSTS policies among term and low birth weight infants is a novel finding. Previous literature suggests that term and low birth weight infants have similar likelihood of CSTS failure as their preterm counterpoints (Bass, 2015 ; Davis, 2015 ; McLaurin-Jiang et al, 2019 ). This is likely due to decreased muscle tone, greater susceptibility to airway obstruction while seated semi-upright, and small size which complicates positioning in car seat.…”

“…Only one infant documented parents declining screening during this study period. Alternatively, when comparing premature Black infants to non-Black infants of the same gestational age, the Black infants are known to have improved respiratory outcomes (Jensen et al, 2018 ; Loftin et al, 2012 ; MacDorman & Gregory, 2015 ; McLaurin-Jiang et al, 2019 ). In addition, small epidemiologic studies have reported lower risk of CSTS failure among Black infants (Jensen et al, 2018 ; McLaurin-Jiang et al, 2019 ).…”

“…Alternatively, when comparing premature Black infants to non-Black infants of the same gestational age, the Black infants are known to have improved respiratory outcomes (Jensen et al, 2018 ; Loftin et al, 2012 ; MacDorman & Gregory, 2015 ; McLaurin-Jiang et al, 2019 ). In addition, small epidemiologic studies have reported lower risk of CSTS failure among Black infants (Jensen et al, 2018 ; McLaurin-Jiang et al, 2019 ). This alternative explanation may lead providers to perceive a decreased risk of car seat associated morbidity for Black compared to non-Black infants and thereby intentionally offer screening less.…”

“…Perhaps supported by increasing awareness of populations at risk for failure, the number of CSTS completed annually has increased within this health care system (McLaurin-Jiang et al, 2019 ). We found increasing adherence to CSTS in both NICU and nursery settings which could be largely contributing to the increasing use of CSTS.…”

“…Standard processes for conducting a CSTS have not been established (Williams & Martin, 2003 ). Initial CSTS recommendations were based on the increased risk of hypoventilation among preterm infants while in car seats (Willett et al, 1986 ), but low birth weight infants have similar rates of failing CSTS (Bass, 2015 ; Davis, 2015 ; McLaurin-Jiang et al, 2019 ). Among the 500,000 US-born infants that are preterm and/or low birth weight each year (Martin et al, 2018 ), the observed rate of CSTS failure ranges from 4 to 10% (Davis et al, 2013 ; Jensen et al, 2018 ; Schutzman et al, 2013 ).…”