Peds, part 2: Principles - Safety - Car Seats, Drowning, Burns, Poisoning, and Choking
by Meris Shuwarger BSN, RN, CEN, TCRN December 15, 2021 Updated: August 09, 2023 6 min read
In this article, we discuss some key considerations of child and infant safety.
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Note that when it comes to car seat safety, the following are the minimal best practices and may not reflect state-specific standards or evidence-based best practices. Knowing your state’s standards when it comes to car seat safety is key.
Different types of car seat
There are different types of car seat for different stages of a child’s development. As your child grows, their car seat style and positioning will change, depending on the child’s height and weight, not their age. The age ranges provided here are for general purposes — the specific car seat required for any child will depend on state law, best practices, and the height and weight requirements of that car seat.
Rear-facing: From birth to 2 – 4 years old, the child should sit in a rear-facing car seat.
Front-facing: From age 2 to 5 years old, the child should sit in a front-facing car seat.
Booster seat: From age 5 until seat belts fit properly (approximately ages 9 to 12 years old), a booster seat is appropriate. This is much longer than most people think their child should use a booster seat. This is because seatbelts are designed for adults; until the child approaches adult size, they should use a booster seat when they ride in a car.
Key points of car seat use
For rear and front-facing car seats, use a 5-point harness. The five points are at the shoulders, the chest clip, and two at the hip.
Position the top straps at or below the child’s shoulders for rear-facing car seats. For a front-facing car seat, position the straps at or above the child’s shoulders.
The chest clip needs to rest at nipple or armpit level — at chest height — and not on the abdomen, which would mean it sits over the child’s vital organs. In the event of an accident, a sudden forward thrust will place immense pressure from the strap on the child’s vital organs, which is why the chest clip should be place higher, over the child’s sternum.
If possible, use the car’s LATCH system (lower anchors and tethers) to secure the car seat, not the seat belts. This will depend on the car, and whether or not it has the LATCH system installed.
Keep children 12-years old and younger in the back seat, even if they are using the car's seat belts (even if they are no longer in a booster). Place the child in the center back seat if possible (this is the safest seat in the event of a side impact). Never place a rear-facing car seat in front of an airbag (don’t install the car seat on the front passenger seat).
The CDC reports that more children ages 1–4 die from drowning than any other cause of death except birth defects. For children ages 1–14, drowning is the second leading cause of unintentional-injury death after motor vehicle crashes. Further, children who suffer a non-fatal drowning are at risk for brain damage and other serious outcomes.
To prevent drowning, the following minimum safety standards should be followed:
- Fence off swimming pools.
- Ensure kids wear life jackets in and around bodies of water, even when being supervised.
- Children should learn how to swim (adults too!), and adults should know how to perform CPR.
- Supervise children in and around any body of water, including bathtubs.
- Close toilet lids, and don’t leave young children unsupervised in the bathroom. Child locks can be used on bathroom doors to ensure an unsupervised child doesn’t wander into a bathroom.
- Be sure all containers with liquids (e.g., buckets) are emptied immediately after use. It only takes a small amount of water for a person (of any age) to drown.
- If a near-drowning incident occurs, always bring the child to the hospital, because fatalities can occur hours later. This is referred to as “dry drowning.”
To prevent burns, following these precautions.
Install smoke detectors in the house. There should be at least one smoke detector per level of the home, and they should be positioned outside of bedrooms (ideally outside of each bedroom — different states may have different laws for the minimum number and placement of smoke detectors). Test all smoke detectors monthly, and replace the batteries every 6 months. A best practice for battery changes is to sync with Daylight Savings Time.
When cooking, use the farthest burners possible and turn pot handles to point to the back of the stove. This prevents children from touching a hot burner or grabbing the handle of a hot pot and pulling it (and its hot contents) down on themselves. Never leave a stove unattended.
Set a house’s water heater temperature at or under 120°F.
Test the water temperature prior to immersing a child in warm (hot) water. Never put a child in water whose temperature has not been tested first. For infants, test the water on your elbow.
Avoid heating foods in the microwave if that food will be served to children. This is due to the potential for superheated areas of the cooked food that can scald a child. Never heat formula or breast milk in a microwave.
Use safety caps to block unused electrical outlets. These are small plastic “plugs” that a child cannot pry loose easily.
Choose pajamas made with fire-resistant fabric. Many pajamas come with warning labels that indicate a snug fit for fire-resistant fabrics.
Poisoning prevention and treatment
There are many things used in everyday life that are poisonous and could cause serious harm if ingested. These are the minimum steps to take to prevent poisoning:
Lock up anything potentially hazardous to the child, e.g., medications, cleaning products, and chemicals.
Educate caregivers and parents to have the poison control number readily available (1-800-222-1222). Program the number in your phone or put it on a refrigerator magnet where it can be seen. Always call poison control first before doing anything else!
Do not induce vomiting in a child who has ingested a poison. And advise parents not to use ipecac syrup to induce vomiting, as infants and very young children are at a greater risk of choking with their own vomit (or getting vomit in their lungs). If a parent or caregiver fears that a child has ingested poison, call poison control or take the child to the emergency room.
Interventions will depend on what the child has ingested. These may include use of activated charcoal, acetylcysteine (for acetaminophen overdose), chelation therapy (for iron or lead overdose), or gastric lavage (pumping out the contents of the stomach).
It is vitally important to know what the child has ingested in order to know how to treat them.
Children, especially small children, like to explore their world — including putting all sorts of things in their mouths. This places them at a risk for choking.
To prevent choking in a child:
Always supervise children during mealtime.
Avoid choking hazards, especially around mealtime. These tend to include anything round or requiring lots of mastication (chewing), for example, hot dogs (cut them into small pieces); nuts and seeds; chunks of meat, cheese, peanut butter, and raw vegetables; whole grapes; hard or sticky candy, popcorn, or chewing gum.
Signs and symptoms of choking
A child who is choking will show the following signs and symptoms:
- Stridor, the high-pitched sound made upon inhalation or expiration, which indicates something blocking the airway
- Dyspnea (shortness of breath)
- Clutching their neck with hands (the universal sign that someone is choking, no matter their age)
- Inability to speak
- Cyanosis around the mouth and face or extremities, indicating a late sign of hypoxia
Interventions for choking
For children under 1-year old, use back blows and chest thrusts.
For children over 1-year old, use abdominal thrusts.
Never perform a blind finger sweep (reaching into the child’s mouth to try to extract the object). This may lodge the object farther into the airway. A child’s airway gets narrower the farther down it extends, so pushing an object farther into the airway means it will be harder to extract that object.
If the child becomes unconscious, begin CPR.
Hi. I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some key considerations for child and infant safety. I'm going to be following along using our pediatric nursing flashcards. These are available on our website, leveluprn.com. If you already have a set of your own, I would invite you to follow along with me. And if you don't have a set yet, what are you doing? Go get a set right now. I promise you, they're going to help you out a whole bunch. All right. Let's get started.
Okay. First up, we are going to be talking about car seat safety. Now, if you've seen my maternity video on this, here is my little disclaimer before we start this. This is based on the minimum best practices. So this may not be what your specific state recommends or what the evidence-based practice says is the maximum best practice, okay? We're talking about the bare minimums. Things may differ based on your state laws or based on the evidence-based practice you read. These are the minimums. So first up, we're talking about the different types of car seats. We have rear-facing, front-facing, and booster seats. Now, rear-facing, this is going to be from birth to 2 to 4 years old. In most states, the law is rear-facing until age 2. However, the evidence shows that it may be best practice to rear-face a child until the age of 4 as long as they do not max out the height and weight requirements of that seat.
Now, front-facing. This is going to be from age 2 until approximately age 5 years old. Again, this means that the child has to be within the height and weight requirements of the seat. This is still a five-point harness. So it's the same type of car seat, just turned around. And in many instances, there are car seats that can be used to rear-face and forward-face. There's even kinds that will convert into high-back boosters as well. Now, booster seats are going to be from approximately age 5 until a seat belt fits properly, which is about age 9 to 12 years old. That is a lot longer than most people may think of. So very important to understand that seat belts, sitting in the seat, is for adults. That has to do with the anatomy of an adult. So a child does not meet those requirements, usually until age 12, and they should still be sitting in the back seat.
Now, key points here. Rear- and front-facing. We talked about that five-point harnesses. So five points. This is going to be shoulders, chest clip, and two levels at the hip, right? So that's very important there. This is so important and a thing that we don't talk about enough. When we are talking about the position of the straps, for a child who is rear-facing, we want the straps to be at the level of the shoulders. So coming out at this level or coming out from a little bit behind that. A little bit below that. Whereas when you are forward-facing, the straps should be coming from above the level of the shoulders. The chest clip must rest at the nipple level or armpit level. Armpit level means here, right? This is chest clip. This is the chest. It needs to go over the sternum, not down here in the belly over those vital organs. Very important teaching there. If possible, we want to use the latch system, not the seat belts. But again, that's going to be based on your car and your seat belts-- I'm sorry, your car seat. And then children less than or equal to 12 years old should be kept in the back seat. Even if they are sitting in the seat with a normal seat belt, back seat. When possible, we want them in the middle of the back seat for side-impact purposes.
Okay. Moving on, we're going to be talking about drowning prevention. Any swimming pools should be fenced off. Very important there. When children are around bodies of water, even though they are supervised, they should still be wearing life jackets. Anyone who is going to be having a pool or doing any sort of fun outdoor water activities, the children should be taught how to swim and the adults should know CPR. We need to supervise children in and around water, including bathtubs. Remember, you can drown in a small amount of water. So in and around bathtubs as well. This is silly, but closed toilet lids. Children play in toilets. And if they fall down face first, they can drown in that water as well. Essentially, do not leave a young child unsupervised in the bathroom, is what I'm saying here. And this is so important and not something that most people know. If we have a near-drowning incident, the child still should be taken to a hospital for emergency evaluation because there is something called dry drowning where we can actually have fatalities hours later. So even if a child appears to be fine after a near-drowning incident, you need to educate the families that they should still seek emergency medical attention.
Okay. Moving on, we're going to be talking about burn prevention in children. So we have to have smoke alarms installed in the house. This is best practice for anyone. This is a soapbox of mine, fire safety, fire prevention. You have to have smoke detectors, and we need at least one for each level of the home. They should be placed outside of bedrooms as well. Think about being able to hear that sound if I'm dead asleep. They need to be tested monthly, meaning that you push the little test button and it chirps and goes, "Yep, I'm working." And we need to replace the batteries every six months. Best practice is going to be to just sync it up with daylight savings time. So any time you adjust your clocks, replace your smoke detector batteries. If you need to replace your batteries, pause this video. Go do it right now. Do it right now. It's very, very, very important. When cooking, we want to use the burners that are the furthest away from the front of the stove as possible. And we want to turn pot handles around so that they are facing the back of the stove, making it very difficult for a child to push it or pull it towards themselves and accidentally pull it down onto themselves.
This one is so important we have it in bold red. Water heater temperature should be set at less than or equal to 120 degrees Fahrenheit. That is a very important way to prevent burns, is by just making it so that that water cannot burn you, right, or is as low as possible there. You got to test the water before you put a child in it. And when we're talking about infants, we're testing that water on our elbows, right, to make sure that it does not feel too hot. Don't ever put a child into water you have not tested first. We don't heat food in the microwave for children because it can create hot pockets within that food, which can scald a child. We never heat up formula or breast milk in the microwave ever, ever, ever. Safety caps. Little outlet plugs should be used to block off unused outlets. And then fire-resistant fabric for pajamas. This is basically just standard practice. If you go buy a child pajamas, you'll see a big yellow tag, usually, that says, "This material is meant to be snug-fitting. It is fire-resistant." That sort of a thing. So, essentially, it's going to fit tighter than regular clothes.
Okay. Moving on to poisoning prevention and treatment. Look at all of this bold red text, very important. So we're going to lock up anything that could be potentially hazardous to a child, including medications. We have to educate caregivers. You must have the poison control number readily available. The last thing you want in an emergency is to be trying to Google search something, right? So just program it in your phone, have it on a magnet on the fridge, something like that. We have the number here. It's 1-800-222-1222. Before doing anything, the caregiver should call that number. Very important, they should not try to induce vomiting using ipecac syrup. We're going to call poison control first before we do anything, and inducing vomiting is not something that a parent should be doing. If that is a concern, they need to go to the emergency room. There are lots of interventions. A lot of it is going to be based on what the child ingested. So, for instance, if they ingested acetaminophen, the antidote would be acetylcysteine. They may need activated charcoal. They may need chelation therapy for lead or iron poisoning. But the point is we need to know what they ingested so that we can know how to treat it.
All right. Moving on to our last topic here, which is going to be choking. So a lot of stuff to know about choking. Choking prevention is very important. We've talked about this before in terms of small children put everything in their mouths, right? And they have an airway that gets skinnier as it goes down, which just puts them at risk for choking, for very severe choking incidents and outcomes. So we want to avoid choking hazards at mealtimes. Big ones here, anything round or requiring lots of mastication, which means chewing. So examples would be hot dogs. If you're giving hot dogs, they need to be cut into quarters. Nuts and seeds, lots of chewing. Chunks of meat or cheese. Peanut butter or raw vegetables. Whole grapes. Hard or sticky candy, popcorn, and chewing gum. Those are just some examples of things we would want to avoid.
Now, when it comes to signs and symptoms of choking, wheezing is possible, but the big one I want you to think of is stridor. Stridor is that high-pitched [gasping], that kind of really high-pitched sound that happens with inhalation or expiration. It is because of a blockage. Very, very indicative of choking. Coughing. Dyspnea. Clutching their neck with their hands. There's a reason that this is the universal sign for choking, is because when you choke, this is the first thing you do, right? So that is true for children as well. Inability to speak and cyanosis. Remember that. Cyanosis around the mouth or the face, the extremities, that is a late sign of hypoxia. We're very concerned at this point.
Now, interventions for choking. For children less than one year, we're going to do back blows and chest thrusts. And over the age of one year, we're going to be doing abdominal thrusts. We don't ever, ever, ever do a blind finger sweep, where we just stick our fingers in their mouths and start sweeping around to see if we can feel what's in there because we could push it down further. And remember, their airway gets narrower. So if you push it down further, it becomes harder to get back out. And if the child becomes unconscious, we are beginning CPR. Okay? Very important stuff to know about choking there.
I hope that review was helpful. Be sure to stay one more minute because I've got some great quiz questions for you coming up to test your knowledge of key facts. Okay. First up, I want you to tell me, at which age should a child be allowed to sit in the front seat of the car? What is the minimum age at which they can sit in the front seat? Okay. Next up. What is the maximum temperature that a water heater should be set to in order to prevent burning? What is the highest allowable temperature there? Third question for you. When should a parent or guardian induce vomiting with ipecac syrup? When is that appropriate?
Last question for you. A parent tells the nurse about their toddler's diet. Which of the following foods listed by the parent requires reeducation by the nurse? Select all that apply, okay? Bananas. Baby carrots. Sliced grapes. Hot dogs. Cubed cheese. Which of those five foods would indicate to the nurse that the parent needs further education? I hope that review was helpful. Thanks so much and happy studying.
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