Concept Analysis: Heat-related Illness
The Dangers of Children Left in Cars
Edward Hynes

Abstract An understanding of the concept of heat-related illness on children in enclosed vehicles and the impact on their families is necessary for Advanced Life Support (ALS) in order to appropriately assess the situation and determine the most appropriate actions to take. This paper will present various aspects of heat-related illness on children in enclosed vehicles, including the causes and outcomes of these situations, the impact on the families, and preventative measures.

Concept Analysis: Heat-related illness
What is the concept of Heat related illness on children in enclosed vehicles and the impact on the family? In todays’ families both parents have to work in order to pay the bills. As a result, both parents have to split the responsibilities of getting the kids from one place to another. The results are we all get involved in our routines that when you change that routine something always gets forgotten. Unfortunately the add responsibility of drop our child off at daycare sometime gets forgotten. And our days go on as normal. Until the dreaded question comes up “Can you pick up the children from daycare?” And your world gets turned upside down and inside out and will never be the same. As you remember you forgot to drop your child off at daycare. You run franticly to your vehicle to find out you are too late and you have lost your child to a heat related illness called heatstroke. And as a result our children are the ones who suffer due to this.

The concept of heat-related illness will be presented in this paper. According to Grubenhoff, du Ford, and Roosevelt (2007), heat-related illness occurs when there is a thermoregulatory disturbance in the body. Environmental heat exposure and increased metabolism cause an increased core temperature or hyperthermia because various factors impair the body’s ability to dissipate the increased heat. The consequences of this state which coincide with the level of heat-related illness are determined by its longevity. The varying degrees of heat-related illness include heat edema, heat syncope, heat cramps, heat exhaustion, and heat stroke (Becker & Stewart, 2011; Yard et al., 2010).
Heat-related illness affects more than the physiological aspects of the victim. It also has psychological effects, especially if the neurological system has been involved. The social impact of heat-related illness is felt in communities during heat waves and in desert-like communities where greenery is limited (Reid et al., 2009). Heat-related illness can affect both humans and animals and studies have been done on both.
Research on heat-related illness has been directed at a multitude of areas. Some investigators focus on antecedents such as exertion and exercise from athletes and migrant workers (Yard et al., 2010; Mirabelli et al., 2010). Other researchers have performed studies on the effects of heat waves on health-related illness (Gonzalez, Halford, & Keach, 2010; Bouchama et al., 2007). Even more studies have been done on predisposing factors such as age, use and abuse of alcohol and drugs, and mental conditions (Poor, 2007; Cusack, de Crespigny, & Athanasos, 2010). Research has even been conducted on the antecedent of place of occurrence (Booth, Davis, Waterbor, & McGwin, 2010; Guard & Gallagher, 2005; McLaren, Null, & Quinn, 2005). Heat-related illness can occur in both animals and humans. Often times, researchers perform studies on animals under heat stress to evaluate outcomes and effectiveness of potential treatments for humans (Sinha, 2009). This demonstrates the need for a thorough understanding of heat-related illness in order to promote optimal health for all species.
Walker and Avant (2005) understanding the concept of heat-related illness in ALS is essential. Mortality occurs in 30-70% of the cases of heat-related illness; therefore, it is pertinent that advanced practice nurses (APNs) be aware of how to assist families during these types of tragedies, including being knowledgeable in available support services and understanding the various aspects of grief. It is also important for medical personel to educate their clientele and the community on the dangers of heat-related illness, especially as it pertains to vulnerable groups such as children, and preventative techniques to utilize in these situations.
The aim of this concept analysis of heat-related illness is to describe: the causes and effects of heat-related mortality of children in enclosed vehicles; the impact these tragedies have on the families; and measures to prevent these tragedies from occurring. This analysis is based on the conceptual framework of Walker and Avant (2005), including the key elements of attributes, antecedents, consequences, and empirical referents. The literature review was performed on Science Direct, Google Scholar, CINAHL and Academic Search Premier using the keywords: heat-related illness, heat stroke, heat exhaustion, and hyperthermia in conjunction with automobile and children.
Literature Review
Affects of Environment on Automobile Interior Temperature McLaren, Null, & Quinn (2005) performed an observational study on the interior temperature rise in a vehicle with the windows completely up and also with the windows cracked 1.5 inches. Measurements of the increase in temperature were taken over the course of an hour. This study demonstrated the interior temperature of a car raises approximately 40o within an hour and incurs 80% of that increase within the first 30 minutes. The study also demonstrated there was not any significant difference in temperature rise between the windows being closed and being partly opened. This study was consistent with previous studies, except for one where 75% of the total temperature increase occurred within the first 5 minutes of the car being in the sun. McLaren, Null, and Quinn stated this rapid increase was probably secondary to the sensor being placed in direct sunlight versus in the shade as done in the current study. The researchers also stated children and infants are more prone to heat-related illness due to increased ratio of body surface area to mass and immature thermoregulatory systems. It was also stated there are limited studies on how quickly children respond to increased temperatures inside cars because it would be unethical to perform such research on them. Gibbs, Lawrence, and Kohn (1995) performed a similar study but utilized both a dark colored vehicle with the windows closed and a light colored vehicle with the windows cracked 1.5 inches. The testing was done on one July day from 2:30-4:00 pm with an outside temperature of 93o. The study showed an inside temperature elevation above 125o in 20 minutes and above 138o in 40 minutes. The researchers noted infants and young children are at greater risk of suffering from heat-related illness because they tend to wear more clothing, sit in cloth seats, and are below the window level where maximum sun exposure occurs. Surpure (1982) also studied outside temperature on the interior temperature of automobiles in order to establish the dangers of children, the elderly, and pets being left in an enclosed vehicle. The study was performed during the first week of July from 8:00 am-4:00 pm. There were some differences in this study. First, the researcher utilized a large and a small vehicle. The results showed the small vehicle heated much more rapidly and to a higher temperature (172o) than the large vehicle (149o). Second, the small vehicle was placed both in the direct sun and also in the shade which did show a slower and lower increase in interior temperature while in the shade (111.2o). Third, the small vehicle was also tested with the windows closed, completely opened, and opened approximately 2 inches. This demonstrated very little difference in temperature increase when the windows were closed and partially open (172o vs. 158o). However, the temperature increase was much lower with the windows completely opened (122o). This study demonstrated direct sunlight and ventilation both play a role in increased temperatures in automobiles during the day.
Effects of Heat-related Illness on Children Krous, Nadeau, Fukumoto, Blackbourne, and Byard (2001) performed a case study of infants and children who had succumbed to hyperthermia death (fatal heat stroke) from either being in a closed vehicle or in a bed. The researchers evaluated 10 cases with 8 of them concerning children who had died within vehicles. The authors combined their results with other cases found in literature. The vehicle-related death statistics for this paper represented a total of 18 children, ages 84 days-9 years. Body temperatures ranged from 98.6o at three hours postmortem to 108o around time of discovery. Several signs of heat stroke death were identified in these cases: interthoracic, cutaneous and conjunctival petechiae; cutaneous burns; dehydration; and early skin slippage. Disseminated intravascular coagulation (DIC) was identified in only 2 cases which involved children who survived 19-70 hours after being discovered. This study also discussed several studies on temperature rise within vehicles. One study which was discussed stated children have developed heat stroke in less than 20 minutes of being left in a vehicle. The literature also revealed there were limited systematic reviews of hyperthermia deaths of children.
Occurrence of Heat-related Child Deaths from Automobile Entrapment Booth, Davis, Waterbor, and McGwin (2010) performed a case study review of 231 heat-related deaths of children from 1999-2007. They gathered statistics from internet searches, the Centers for Disease Control (CDC) WONDER database, and Golden Gate Weather Service (GGWS) database. The researchers found: 30% of the children were <1 year; 64% were 1-4 years; 5% were 5-9 years; and 1% were 10-14 years. Children playing in vehicles unattended were cited in 58 of the 231 cases. They also determined 192 of the children were left unattended with 75.5% being unintentionally left, 13% being intentionally left, and 11.5% having unclear intentions. The mean core body temperature of these children was 107o and the average length of time in the vehicle was 4.6 hours. The geographic area involved 160 counties and 41 states. The researchers cited several limitations, including lack of a nationwide database, death certificates listing hyperthermia as a secondary cause of death, and most data collection originating from news articles where validity and reliability may be in question. The authors also noted there had only been one other peer reviewed article evaluating heat-related deaths of children in automobiles. Null (2011) has compiled the Golden Gate Weather Service database which keeps detailed statistics regarding reported heat-related deaths of children in cars. As of November 18, 2011, there have been 524 recorded vehicle-related heat stroke deaths of children. There have been 30 deaths in 2011 so far and there were 49 in 2010. The yearly average has been determined to be 38. Null has determined: 51% of these children were unintentionally left in the vehicle; 30% became trapped after playing in an unsupervised vehicle; 17% were intentionally left; and 1% had unknown circumstances. Null has determined from available data there were only 11 instances of vehicle-related heat stroke deaths in children prior to the implementation of airbags in all vehicles.
Impact of Vehicular Heat-related Deaths in Children on Their Families Dennis (2007) wrote about the death of a 2 month old whose mother had unintentionally left him in the car all day while she worked. Dennis discussed how the mother required sedation and how family and friends were in a state of shock. The article included an email from the father of the child who stated he stood by his wife and she was a wonderful, caring mother who loved her sons above anything else. Dennis also discussed how the mother was potentially going to be charged for the death of her infant son. Dennis documented a conversation with another mother whose child had died the same way. The mother talked about the pain, the off-handed comments made by people who couldn’t or wouldn’t understand, and the effect it had had on the family. The website, www.4rkidssake.org, has a section called, Our “Littlest Angels” (2010). This area is for families to post stories about their deceased children. The family members discuss the joy of pregnancy and having a baby, the specialness of their children, and the grief and pain they are feeling.
Key Elements of the Concept Analysis
Defining Attributes Walker and Avant (2005) have stated the defining attributes of a concept are those characteristics that reoccur throughout the literature review. In regards to the concept of heat-related illness in children in enclosed motor vehicles, the commonalities have been described as: infants and children being at higher risk for heat-related illness; heat stroke, including a core body temperature exceeding 104o; children being unattended in a vehicle; and the effects of direct sunlight and lack of ventilation on the increase in temperature on the inside of vehicles.
Antecedents
Walker and Avant (2005) have defined antecedents as circumstances which must happen before the concept occurs. Possible antecedents for the concept of heat-related illness with regards to vehicle-related child death have been described in the literature as: increased responsibilities and distractions of the child’s caregiver; infant or child sleeping in the backseat of the car out of direct line of sight of the caregiver; or a recent change in routine of the caregiver.
Consequences
Walker and Avant (2005) have stated the consequences are the outcomes which result from the concept happening. In regards to the concept of heat-related illness, heat stroke and consequential death are almost always the results of vehicle-related incidents. Another consequence of these tragedies is the pain and suffering the families have to endure.
Empirical Referents Walker and Avant (2005) have defined empirical referents as authentic data which reinforces the attributes of the concept. Null (2010) has developed a thorough database which illustrates the empirical data necessary to support the concept of heat-related deaths of children in vehicles. Each child’s name in this database has been given a link to the news article describing the occurrence and its outcome.
Model Case The website, www.4rkidssake.org, has several examples of model cases for the concept of heat-related deaths of children in enclosed vehicles. The following link will take you to the tragic story of a 3 ½ month old baby: http://www.sptimes.com/2004/08/01/Citrus/Grief__shock_engulf_l.shtml Conclusion Heat-related deaths of children in enclosed vehicles continue to be a serious socio-cultural problem nationwide. The extensive literature review done for this paper demonstrated several limitations in the current research. First, there is no research concerning the knowledge base of parents and caregivers regarding the dangers of children being unattended in automobiles. Second, there are very few articles which address possible prevention techniques, such as car seat alarms and visual cues.
The concept of heat-related deaths of children in enclosed vehicles is a national problem which requires the attention of the legislator to achieve the desired education and prevention that is necessary to stop the senseless loss of our precious children. New legislation could require mandatory education programs in high school child development, parenting and childbirth classes. Safety education could be added to the current car seat safety programs offered at local health departments. The use of public service announcements on radio and television during the late spring and summer months would also serve to educate the public. New legislation could enforce the implementation of child safety alarms on all car seats and booster seats. Currently, these devices are optional and not well advertised, and so many people are unaware of the availability. These alarms would prevent the needless loss of children, the unending grief of families, and decrease the costs procured in prosecuting the caregivers who made these disastrous mistakes. As advanced practice nurses, it is important to have a thorough understanding of this problematic concept. Nurse practitioners could provide necessary education on the dangers of children in cars and also on prevention techniques for parents and caregivers to follow. Advanced practice nurses could also join together in support of the above mentioned suggested legislation in order to resolve this problem all together.

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