Restraints for Children with Special Health Care Needs
CONVENTIONAL CAR SEATS
Conventional car seats are appropriate for many children with special health care needs. Conventional car seats are defined as those restraints that meet Federal Motor Vehicle Safety Standard 213. Conventional restraints can be purchased at retail stores and are not specifically designed for children with special health care needs. Examples include rear-facing only, convertible (all-in-one), combination seats, and belt-positioning boosters. Seats with harnesses to higher rear-facing and forward-facing weight limits have increased the number of conventional car seat options available for children with special health care needs.
American Academy of Pediatrics Conventional Car Seat Product Listing – Includes weight and height limits, pricing, and is separated by Rear-Facing Only Seats, Convertible Seats (All-in-One Seats) Combination Seats, and Belt-Positioning Booster Seats, Travel Vests, and Other Seats.
Rear-Facing Only Seats
Rear-facing seats, which include rear-facing only car seats and convertible car seats, provide appropriate protection for many children with medical conditions. Weight maximums as high as 30-35 pounds are not uncommon in rear-facing only car seats and as high as 40-50 pounds in rear-facing convertible car seats to allow some children with special health care needs to ride rear-facing longer.
Many rear-facing car seats come with infant positioning inserts and head support systems that provide adequate lateral support for infants. Some support systems are designed specifically for use by smaller infants or infants born prematurely.
Select car seats with smaller internal dimensions for smaller infants who do not experience cardio-respiratory events. If infants weigh less than five pounds, select a seat with a lower minimum weight limit with many starting at 4 pounds and some starting at 3 pounds. Maintain an appropriate angle during car seat tolerance screening and vehicle installation.
According to current safety recommendations, children are best protected in a crash if they are seated facing the rear of the vehicle as long as possible, at least until they are about two years of age, or have outgrown the rear-facing weight or height maximums for the car seat.  Many convertible car seats can be used rear-facing to weights as high as 40-50 pounds. These seats allow larger infants and toddlers with special health care needs to ride rear-facing longer.
Convertible Seats
In general, convertible car seats are designed for rear-facing use for infants and forward-facing use for toddlers. They are “converted” from an infant seat to a toddler seat by making specific changes, according to manufacturer’s instructions.
Keep your child rear facing as long as possible.  Riding rear-facing helps support your child’s entire body and protects better from an injury, especially to the spine. Most newer convertible car seats are approved for rear-facing up to 40-50 pounds and should be considered for infants whose height and weight have exceeded the limits of the rear-facing only car seat (Check manufacturer’s instructions for weight limits). Move your child into a rear-facing convertible car seat when outgrowing the rear-facing only car seat.  Convertible car seats that are rear-facing to higher weights can also be beneficial to many children with special health care needs. For example, children of smaller stature, developmental delays, brittle bones, down syndrome, hydrocephalus, low tone, and poor upper body control will be better positioned and protected when riding rear-facing.
Forward-Facing Car Seats
Forward-facing car seats, including convertible seats and 3-in-1 car seats, with upper harness limits up to 65 pounds are readily available. These forward-facing car seats provide some children with special health care needs the opportunity to benefit longer from the protection offered by a five-point harness.
Some features that may benefit children with special health care needs are as follows:
- Harnesses that can be used up to 65 pounds provide more time in a 5-point harnessed restraint for children with behavioral challenges, positional issues, or obesity.
- Car seats with lower or shallow sides may accommodate some children in leg casts including long-leg broomstick or hip casts.
- Forward-facing car seats with multiple recline options may assist with positioning children with poor head and neck control and who have outgrown the rear-facing limits of their car seats.
- Extra padding and positioning inserts. Seats with these features can provide better positioning or comfort for children with neuromuscular or bone dysplasia conditions.
Belt-Positioning Booster Seats
In order to use a belt-positioning booster seat, a child with special health care needs must have good head, neck, and trunk control. Boosters with higher weight limits may be suitable for children who are overweight or obese. Extended booster use is recommended for children smaller than their typically developing peers, such as children with achondroplasia. High back boosters with sides may provide adequate lateral support for some larger children who experience intermittent fluctuations in trunk control. These booster seats may also assist with children with behavioral problems by improving their comfort by allowing their knees to bend and their legs to hang down. Compliance may also improve as the child is able to see out the window.
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ADAPTIVE RESTRAINTS
In general, adaptive restraints are designed specifically for children with special health care needs and are not available at retail stores. They are ordered through a local durable medical equipment vendor or in some cases ordered directly from the manufacturer. Adaptive restraints are more expensive than conventional car seats and securing funding can be challenging. Adaptive restraint loan programs are often available through hospitals, local Easter Seal affiliates, health departments, and Safe Kids coalitions. Third-party payers including Medicaid may cover the cost of adaptive restraints when sufficient documentation of medical necessity is provided.
National Center for the Safe Transportation of Children with Special Health Care Needs Brochure (Inside) – Includes images and information on available adaptive restraints.
The following section describes general information about categories of adaptive restraints. It does not provide information about specific restraints. Â
Car Beds
Car beds are designed for infants who must travel lying down. Car beds may needed for infants who have cardio-respiratory conditions, lower extremity casts, omphaloceles, midline chest defects, abdominal defects, or neuromuscular disorders. Use of car beds should be for those infants who demonstrate a medical necessity and MUST travel lying down. Infants discharged in car beds should have a period of observation in the car bed prior to discharge (Car Seat Tolerance Screening) to ensure positioning in the car bed will not exacerbate any of the infant’s symptoms. Additionally, when the physician determines the infant may transition to a conventional rear-facing car seat, a follow-up period of observation (Car Seat Tolerance Screening) in that particular rear-facing car seat should be conducted to make sure the infant is capable of the transition to a rear-facing position.
Current car beds include the Angel Ride, Dream Ride, and Hope Car Bed.
Adaptive Rear-Facing Only Seat for Children with Omphaloceles
Consult with the child’s healthcare team to determine the best options. There is one rear-facing only adaptive car seat specifically designed for a child with an omphaloclele (the Jefferson), however can be used for any child who needs the yoke harness system. The yoke harness system that routes around the abdomen and has an adjuster on each harness to compensate for irregularities. Contact Shayne Merritt at info@merrittcarseat.com for further information.
Adaptive Restraints for Children in Casts
There are a small number of adaptive restraints designed specifically for children in casts. Each restraint offers its own method of accommodating hip casts (i.e., hammock, wedges, inserts, etc.), but all feature a wide base with low-profile. These restraints vary from car beds to vests for lying down, convertible car seat to forward-facing only car seat. Each restraint has a different weight and height range.
Current options include the Hope car bed, convertible Wallenberg, forward-facing Spirit Spica, and Lay Down EZ-ON Vest (formerly Modified EZ-ON Vest). For some children who do not fit within the previous restraints – non-emergency professional medical transport may need to be considered.
Large Medical Seats
Large medical seats are designed for children who require additional positioning support from a car seat beyond that offered by a conventional restraint. Upper weight limits range from 102-130 pounds, upper height limits range from 60-66 inches depending on the restraint.
It’s important for families to work with an occupational therapist (OT) or physical therapist (PT) who has experience working with pediatric patients and is a child passenger safety technician (CPST). OTs or PTs will be able to evaluate a child’s positioning needs and determine which restraint provides the best positioning options for the child. Some OTs and PTs who are not CPSTs will work together with a CPST to determine positioning needs and which restraint is best for a child.
Current large medical seats include the IPS car seat, Defender Reha, Roosevelt, Special Tomato Car Seat, Spirit, and Spirit Plus.
Adaptive Booster Seats
Adaptive boosters must be used with the vehicle’s lap-and-shoulder belt system to provide occupant protection. The harnesses in the adaptive booster seats are for positioning only to provide supplemental support to a child with special health care needs. Depending on the booster, they may also have accessories that aid with positioning, such as abductors/pommels, support pads, lap trays, foot rests, and rotating bases. Upper weight limits range from 108-225 pounds, with upper height limits range from 60-72 inches depending on the restraint.
The evaluation and ordering process is similar to that for large medical seats.
Since they are not installed like a large medical seat, adaptive boosters may be options for families who difficulty transferring their child from one vehicle to another frequently.
Current options include the Carrot 3 Child Restraint, Carrot 3 Booster, Churchill, Special Tomato Booster, Recaro Monza Nova Reha 2, and Hercules Prime.
Adaptive Vests
There are a number of vests or harnesses designed for children with special health care needs to use in passenger vehicles.  Upright, seated vests usually fit children from 2 years of age and 31 pounds up to 225 pounds. Some adaptive vests can be ordered with rear zipper closure systems to decreased escaping behaviors. Typically, an upright vest will not provide adequate support for a child with poor head, neck, and trunk support.
One model of vest is for children who need to travel lying down during travel (Lay Down EZ-On Vest/503 – previously the Modified EZ-ON Vest). It is for children ages 1 year and older and 22-106 pounds. In order to use this vest, the child must be able to fit lengthwise on the vehicle bench seat. This vest is an option for older children in hip spica casts or for older children who must lie down during travel.
Current adaptive vest options include the Chamberlain, EZ-On Vest with back zipper/303Z, EZ-On Vest with front push button/403PB, EZ-On Max PV, and Moore Support Vest.
Additional adaptive vests are also used in school buses.
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Adapted Vehicles/Wheelchair Accessible Vehicles
Some families may require use of adapted vehicles in order to meet the transportation needs of their children. The National Highway Traffic Safety Administration (NHTSA) publishes a brochure, “Adapting Motor Vehicles for People with Disabilities,” to assist families to navigate the process of securing adapted vehicles. In general, NHTSA recommends that families work with a driver rehabilitation specialist who is qualified to assess the family’s specific transportation needs and provide them with a list of appropriate vehicle modifications. Although driver rehabilitation specialists typically work with drivers with disabilities, they can also evaluate the vehicle needs of passengers with disabilities. Names of qualified evaluators can be obtained by contacting a local rehabilitation center or the Association for Driver Rehabilitation Specialists at aded.net.
Once the vehicle modifications have been evaluated and discussed with the family, appropriate vehicle options can be explored. When choosing a vehicle, it is important for families to work with a reputable dealer of adaptive vehicles. The vehicle should be equipped with seat belts, vehicle seats, and tether anchorage locations that meet all applicable federal safety standards. The vehicle seat belts should be capable of remaining locked during normal driving conditions if car seats are installed. If the vehicle is adapted to accommodate use of a wheelchair, it should provide adequate space for the wheelchair to face forward, use a four-point tie down system, and a separate three-point seat belt for the wheelchair occupant. In addition, the vehicle should be equipped with appropriate restraint systems for all other occupants.
New adapted vehicles/wheelchair accessible vehicles can be expensive – adding $10,000 to $30,000 to the traditional sticker price. NHTSA suggests that families pursue both public and private avenues for funding the vehicles. For example, insurance companies may cover costs associated with evaluations and vehicle modifications. Adapted vehicle manufacturers may offer rebates or reimbursement plans. Social service agencies may be able to help families explore applicable grants.
Rotating vehicle seats – like the BraunAbility Turny Evo Seat – are also available. If purchasing an accessible van is cost-prohibitive, a rotating/swiveling vehicle seat may be an option. The rotating/swiveling vehicle seat moves out and next to the vehicle making transfers safer and easier to from a wheelchair.
Wheelchair Information
If possible – your child should ride in the appropriate restraint in the vehicle seat instead of the wheelchair.  If transferring is not possible, or if the rider requires the support of the wheelchair seating system, it is very important to secure the wheelchair to the vehicle and restrain the rider in the wheelchair with crash-tested lap-and-shoulder belt restraints. When securing the rider, upper and lower torso (lap) restraints are required. Lap belt angles between 30-75 degrees to vertical are recommended. Both the wheelchair and the rider should face forward in the vehicle. If possible, tie downs, restraint belts, and wheelchairs that meet current standards should be used. The use of a transit-equipped wheelchair that has been crash tested is safer to use in a vehicle as it will have the appropriate tie-down locations.  If your child is transported in the wheelchair on the bus or the family vehicle you can find a detailed information at the University of Michigan Wheelchair Transportation Safety website describing best practices when using a wheelchair as a transportation device.
MISCELLANEOUS
Head/Neck Collars
A child who has decreased head and neck control will eventually need to be positioned forward-facing in a vehicle. Although there are neck collars that provide supplemental neck support, their use during transport in vehicles is of concern. Recent crash tests of a variety of neck collars indicate that most models increased neck tension. The crash tests suggest that stiff and formed neck collars should be removed prior to transport and replaced with softest, foam cervical collars during travel. A change from a rigid neck collar to a soft cervical collar must be approved by the physician who prescribed the rigid neck collar with a written order – as this is not a caregiver or CPST choice.
Note: A child’s head should never be secured to a restraint in an attempt to prevent the head from falling forward. Many items are sold online and elsewhere – however they are not safe to add to any conventional car seat or any adaptive restraint. With that said – there is one exception that has been crash-tested to be used with a specific restraint. One manufacturer offers a cap accessory that attaches with Velcro. This product has been crash-tested to be used with the Merritt Manufacturing Roosevelt large medical seat and Merritt Manufacturing Churchill adaptive booster seat only. No other car seat or restraint can use the Merritt Manufacturing cap accessory at this time.
Medical Equipment
Medical equipment can quickly become a projectile. To date, there is no product available designed specifically to secure medical equipment, such as apnea monitors or oxygen tanks, in a vehicle. Current recommendations for securing equipment include placing it on the floor as low as possible in the vehicle wedged with pillows, foam, or blankets. Some newer vehicles have airbag sensors under vehicle seats that might not allow medical equipment to be placed under the seats. Refer to the specific vehicle owner’s manual for details. If a vehicle prohibits placing items under a vehicle seat – securing the medical equipment with vehicle seat belts in unoccupied vehicle seats is also an option.
Modifying Restraints
Conventional car seats or adaptive restraints that have been structurally modified should not be used unless they have been crash tested with the modification to conform to federal motor vehicle safety standards. What might seem like a minor structural modification can greatly compromise the performance of the restraint in a crash and place the occupant in jeopardy. Please refer to specific manufacturers for details.
