Joseph was a 28-pound 4-year-old with spastic quadriplegic cerebral palsy who was starting pre-kindergarten. Because of his mobility needs, he was transported to and from school in his wheelchair. The school bus drivers anchored the wheelchair to the floor supports and used the seatbelt system of the school bus to secure Joseph in his chair.
One afternoon, Joseph’s teachers noticed that the shoulder strap of the seatbelt laid over his neck and led to discomfort, and he was crying when he arrived at school. They also had concern that his head and neck were not adequately supported. The school district transportation director called the family to update them on Joseph’s experience that day, and the family called his pediatrician for advice.
What advice should the pediatrician give to the family?
Updated recommendations in the AAP policy statement School Bus Transportation of Children With Special Health Care Needs, from the Council on Injury, Violence and Poison Prevention, can provide guidance. The policy is available at https://doi.org/10.1542/peds.2018-0513 and will be published in the May issue of Pediatrics. There are 10 recommendations in the policy, with additional considerations for safe transportation.
Joseph’s pediatrician recommended that he be transferred to a forward-facing car seat with a five-point harness properly attached to the school bus seat. If possible, the car seat should have a recline option to help support his neck and head (see resources).
All children should be transported safely to school in accordance with best practice guidelines. For example, any child who can transfer from a wheelchair should be transported in a school bus seat, as the best seating system is the school bus seat with an appropriate harness system for size and physical/developmental condition.
For children who are too heavy to be transferred or who cannot otherwise do so, a transit option wheelchair may be used correctly anchored to the school bus. The student should be restrained appropriately in the wheelchair with both a postural support (if needed) and the school bus lap/shoulder bus restraint system appropriately applied. Transit option wheelchairs are crash tested, and these seats meet voluntary standards for safety.
Any equipment needed to safely transport the student should be stored during transport in a manner consistent with the wheelchair manufacturer and the bus manufacturer/school district rules and regulations. Lap tables should be removed from the chair and stored properly since they could injure a student during a crash.
Transportation issues need to be discussed and appropriate transportation plans outlined and agreed to during the student’s annual Individualized Education Program meeting. Routes, proximity to first responders and emergency plans should be discussed with school administrators and transportation directors (including the bus driver) in collaboration with the student, family, school nurse, primary care provider (if possible), teacher and aides. All parties involved in the education and care of the student should be included to provide optimal input to the transportation process.
Often, students begin and end their day on a school bus, and careful consideration to transportation details can improve the safety and enjoyment of the student’s school experience.
Dr. O’Neil is a lead author of the policy statement and a member of the AAP Council on Injury, Violence and Poison Prevention Executive Committee.
