Children in adaptive strollers and pediatric wheelchairs: secure the chair or move the child to a car seat

An adaptive stroller is a wheelchair

Treat an adaptive stroller as a mobility device, not a baby stroller, starting at booking. In the ADA’s transportation rules, a wheelchair is any device with three or more wheels, usable inside a building, that was designed or modified for people with mobility impairments, whether pushed or powered (49 CFR 37.3). Read plainly, that wording covers an adaptive stroller built for a child with a mobility impairment.

That brings the ADA’s securement rules with it. 49 CFR 37.165 applies to private carriers too, and it sets four ground rules:

• A securement system has to be used to keep the chair in its spot.
• You can insist on securing the chair.
• Proposing a vehicle seat is allowed. Insisting on one is not.
• Turning the trip down because the chair secures poorly is not allowed.

The catch is that many adaptive strollers were never designed to protect a child in a crash. The University of Michigan Transportation Research Institute (UMTRI) explains that the crash-tested “transit option” is an upgrade bought on top of a basic chair. Its standards are voluntary, the FDA does not require them, and neither does the CMS coding body, so families and therapists have to justify paying for it case by case. The child in front of your van may be sitting in a chair that was never tested.

Car seat first, when the child can move

When a child can be lifted out safely, a car seat is the better place to ride. UMTRI’s Ride Safe brochure ranks a move out of the wheelchair first: into a vehicle seat with its own belt, or into a child safety seat that meets federal standards, with the empty chair stowed and tied down. Since the rules only let you recommend that move, explain the reason to the parent when booking rather than at the curb.

Ordinary car seats do not fit every child, and special needs seats exist for that gap. The American Academy of Pediatrics lists the options parents use:

• Recline. Forward-facing seats with a recline feature help children with disabilities who cannot hold their head and neck straight.
• Travel vests. Vests fit children from 22 to 168 pounds and are an option for some special needs and for children too heavy for car seats. Most need a top tether, so check that the seat position in your van has a tether anchor.
• Car beds. Babies who must lie flat may ride in a car bed that meets Federal Motor Vehicle Safety Standard 213, once a hospital screening shows they can lie in it safely.

For older children and teens, makers build larger special needs seats. As an example, Convaid’s Carrot 3 fits children from 40 to 108 pounds and 43.3 to 59 inches tall, and its back reclines from upright to flat.

In many programs the family supplies the seat. Virginia’s MTM Health member handbook puts it on members to bring a suitable car or booster seat for each child. Which programs say what, and what happens when the seat is missing, is covered in children on NEMT rides. If the parent needs help choosing a special needs seat, the AAP points to the National Child Passenger Safety Certification program’s Find a Tech search, which lists technicians trained in transporting children with special needs.

Checking for a transit option

Look before you load. A transit-ready stroller shows its rating on the frame, and one without it does not.

Ride Safe describes what to look for. A WC19 chair carries a label, either the words or a round logo, and four crash-tested points for the tiedown hooks, each marked with a hook symbol. UMTRI’s note on paying for the option adds one more visible sign: a pelvic belt attached to the chair frame itself. The frame, the four points, and that belt have all survived a 30 mph sled test at 20 g.

Two strollers of the same model can differ. As an example, Convaid offers a “transit ready frame” meeting WC19 and a crash-tested transit lap belt as options on its adaptive strollers, including the Cruiser, EZ Rider, Rodeo, and Trekker. A stroller ordered without those options can look much the same and still lack the tested frame.

Check the transit weight limit as well. Convaid lists its smallest Cruiser frames at 75 pounds of capacity but 66 pounds in transit, and its largest at 250 pounds but 170 in transit. A growing child can outgrow the transit rating while still fitting in the seat.

With no label, no hook symbols, and no frame-anchored belt, treat the stroller as untested.

Securing a stroller with the child in it

If the child stays in the chair, every step below matters more than it would for an adult in a heavy wheelchair, because a small chair moves easily. Broker wheelchair rules apply too: MTM Health’s Virginia member handbook, for one, requires drivers to secure each wheelchair facing forward with four straps and a lap and shoulder belt. The full adult procedure is in wheelchair securement standards.

1. Face forward. Point the chair toward the front of the van, as Ride Safe directs.
2. Use four straps from a crash-tested system. Choose a tiedown labeled as meeting ANSI/RESNA WC18. On a WC19 stroller, hook to the four marked points and pull out all slack. Ride Safe does not recommend clamp-type devices.
3. On an untested stroller, hook only to structure. Ride Safe points to frame junctions that are welded, or joined with hardened steel bolts, and warns against anything adjustable, moving, or removable, such as arm supports, foot supports, and wheels. On a folding stroller, that rules out the fold joints and any adjustable push handle.
4. Belt the child, not just the chair. Put a crash-tested three-point belt or a child restraint harness on the child. Ride Safe warns that the positioning belts on a chair cannot hold a child in a crash. Convaid’s transit lap belt, for example, connects to a shoulder harness anchored to the bus or van and is used in addition to the positioning belt.
5. Bring the tilt up. Some adaptive strollers tilt in space. The Convaid Cruiser, for example, tilts 30 degrees. Ride Safe advises riding with the backrest no more than 30 degrees from upright. On an untested stroller with a tilting seat, choose one part of the frame for every hook, seat or base. Straps split between the two can loosen when a crash changes the seat angle. More on travel positions is under tilt-in-space wheelchairs.
6. Remove what the child could hit. Ride Safe advises taking off a hard tray and securing it elsewhere in the van, and choosing a soft collar over stiff collars or head straps when the child needs head support. Trays and head supports are covered further in transporting cerebral palsy riders.
7. Strap down the equipment. Feeding pumps, suction machines, and oxygen get fastened to the chair or the van so they cannot fly forward.

When the child moves and the stroller rides empty

A folded stroller is heavy cargo. Ride Safe tells wheelchair travelers to secure equipment so it cannot break loose and injure someone in a crash, and an unsecured folded stroller behind a child’s seat is exactly that risk. Strap it down with cargo restraints or into an empty wheelchair position, and keep it off the seats. Load it last at pickup so it comes out first at the clinic door.

Questions to ask the parent at booking

Most answers rarely change, so record them once and confirm them when something does. For school routes, the district may already have this information; see district school routes for students with disabilities.

1. How old is the child, and what are their current weight and height?
2. Does the child ride in an adaptive stroller, a pediatric wheelchair, or a power chair? What make, model, and frame size?
3. Does the chair have a WC19 label, four hook-symbol points, and a pelvic belt fixed to the chair?
4. Can the child move to a car seat, and will you bring one that fits, such as a special needs seat or vest?
5. Is there a tray, head support, or equipment like a feeding pump, suction, or oxygen?
6. Who is riding with the child? Program age rules for the adult are covered under escorts and attendants.
7. Will the stroller be needed at the destination, or can it stay home?

Planning these rides in HealthRide

A child who stays in the stroller goes into HealthRide as a wheelchair trip, and wheelchair needs are matched to vans with a wheelchair space. The parent riding along is added as an escort and takes a seat, so the van is planned for both. You assign the trip from the dispatch board.