The Car Seat Challenge for Premature and Small Babies

Key takeaways: Some babies, especially those born before 37 weeks, can have breathing pauses, low heart rate, or low oxygen in a semi-reclined car seat. A car seat test (often 90 to 120 minutes) checks for this before discharge. Babies who don’t pass may need a different seat position or a car bed.

Before some babies go home, they sit in their own car seat for a monitored test. This is often called the car seat challenge, infant car seat test, or angle tolerance test.

Why It’s Done

In a semi-upright position, some babies’ heads can fall forward, narrowing the airway. Premature and low birth weight babies have less head and neck control and less mature breathing patterns, so they’re at higher risk of breathing pauses (apnea), slow heart rate (bradycardia), or low oxygen levels in a car seat.

The AAP recommends that preterm infants (born before 37 weeks) have a period of observation in their car seat before discharge. Hospitals may also test other babies at risk, such as those with low muscle tone or certain medical conditions. Practices vary between hospitals.

How the Test Works

• Your baby is buckled into your own car seat, correctly positioned.
• Monitors track heart rate, breathing, and oxygen levels.
• The test usually lasts 90 to 120 minutes, or about as long as your trip home, depending on hospital policy.
• Nurses watch for breathing pauses, low heart rate, or low oxygen.

If Your Baby Doesn’t Pass

• The care team may adjust positioning and retest.
• Your baby may need to wait and retest later.
• Some babies go home in a crash-tested car bed that lets them lie flat.
• Your care team will look for causes and may continue monitoring.

At Home

• Minimize time in the car seat for preterm and young babies, and avoid long trips if you can in the early weeks.
• Have an adult ride in the back seat to watch your baby when possible.
• Never use the car seat for sleep outside the car.
• Use only inserts that came with your car seat.

The Bottom Line

The car seat challenge helps ensure that preterm and at-risk babies can ride safely in their seats. If your baby needs extra steps, your care team will help you find a safe option.

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Sources

1. Bull MJ, Engle WA; Committee on Injury, Violence, and Poison Prevention; Committee on Fetus and Newborn. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics. 2009;123(5):1424-1429.
2. Davis NL. Car seat screening for low birth weight term neonates. Pediatrics. 2015;136(1):89-96.
3. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008;122(5):1119-1126.
4. Liaw P, Moon RY, Han A, Colvin JD. Infant deaths in sitting devices. Pediatrics. 2019;144(1):e20182576.

This article is for general education and is not a substitute for individualized medical advice. Always talk with your baby’s health care provider or your own provider about your specific situation. If you think your baby or you may have a medical emergency, call 911.