Car Seat Safety for Premature Infants

Premature Baby Comes Home on Oxygen
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Car seat safety is extra important for premature infants, who may be so small that they barely fit in a car seat or who may have respiratory problems that make it hard for them to breathe well while sitting in one. By choosing the right car seat and making sure that your premature infant is positioned correctly, you can make sure that your baby is safe in the car.

What Kind of Car Seat Is Best for a Preemie?

Choosing the right car seat is one of the most important steps in ensuring car seat safety for your premature infant. Many preemies will go home below the lower weight limit for many car seats, so choosing a seat that will fit a very small baby is important.

There are two types of car seats to choose from:

  • An infant carrier is a car seat for infants only. Infant carriers have a handle and come with a base that is secured into the car so that the seat can be easily removed to carry the baby.
  • A convertible car seat can be used rear-facing for infants and older babies or front-facing for toddlers. Convertible car seats don't have handles, so they can't be used as infant carriers. But they can be used through infancy and toddlerhood, so they help save money.

Whichever type of car seat you choose, pick one that will fit a very small infant. All car seats have shoulder straps that can be adjusted based on the baby's size; look for one with the lowest setting that is 8 inches from the seat or lower. Also, look for a car seat with a crotch strap or buckle position that can be adjusted so that it is snugger to fit a smaller baby. Finally, look at the weight limit. Many car seats will fit babies as small as 4 pounds.

How to Position Your Baby

Choosing the right car seat is only the first step in car seat safety for preemies. Positioning your premature infant safely in the car seat is another important step.

If your baby was small at birth or was born premature, you may have an appointment with an occupational or physical therapist to help you learn how to position your baby in a car seat.

Some of the things they will look for include:

  • Strap/Harness Tightness: Shoulder and crotch straps should be adjusted to their smallest positions. When your baby is in the car seat, you should not be able to pinch the strap fabric together. The chest clip should be at the mid-chest level, at about the level of the armpits.
  • Fit: If your baby doesn't fit securely in your car seat with the straps at their smallest settings, your therapist may show you how to use blanket rolls and a washcloth to help improve the fit. Only use blanket rolls if your nurse or occupational/physical therapist tells you to do so and shows you how.
  • Positioning aids: Some car seats come with positioning aids that add extra padding to help keep newborn babies upright in the car seat. These are fine if they came with the car seat, but do not use positioning aids that were bought separately, as they were not tested with the car seat for safety.

Where to Place the Car Seat

The safest place for any baby is in the middle of the back seat. An adult should sit in the back seat with the infant whenever possible. Never place a rear-facing car seat in the front seat of a vehicle with front airbags; serious injury or death could occur if the airbags deploy.

How Does Extended Rear-Facing Impact Car Seat Safety?

The American Academy of Pediatrics recommends that infants ride in rear-facing car seats at least two years or until the baby outgrows the seat.

The American Academy of Pediatrics recommends that all infants ride rear-facing until age 2 because studies show that extended rear-facing is much better at protecting babies from severe injuries.

Especially for preemies, who may be smaller than their peers and may have delayed motor development, using a rear-facing car seat is the safest option. When your baby outgrows the weight limit for his or her infant carrier, you can use a rear-facing convertible car seat.

How to Protect Your Preemie's Airway in a Car Seat

Premature babies may have breathing problems that make it hard for them to breathe well in the semi-reclining car seat position.

Once you get your baby home, there are steps you can take to make sure he or she can breathe well in the car seat:

  • Wait an hour after eating: Especially if your baby has reflux, wait about an hour after feeding time before getting in the car seat. This will allow the feeding to digest and will help prevent regurgitation.
  • Have an adult ride in the back seat: Until your baby is able to maintain a good position in the car seat, it is safest to have an adult ride in the back seat with the baby. If the baby begins to slouch or spits up milk, that person can reposition or suction the baby.
  • Take short trips: During the first few months of life, keep car trips to an hour or shorter. If you must be in the car for longer periods of time, stop for rest breaks frequently.

Car Seat Tests for Preemies

The car seat test makes sure that premature babies are able to sit in a car seat safely, without any episodes of desaturation, apnea, or bradycardia. Most preemies will have a car-seat challenge in the NICU to make sure that they can ride safely in a car seat.

The American Academy of Pediatrics recommends a car seat test, or car seat challenge, for all babies born before 37 weeks gestation.

If your baby does not pass this car seat challenge, he or she will need to grow a little bigger before having the test repeated. Some babies who are unable to pass the car seat challenge may need to ride in a car bed for safety.

Premature babies may have a variety of medical conditions that make a car seat challenge necessary. Their airways are weaker than the airways of full-term babies and may collapse when preemies are placed in the semi-reclined position that car seats use.

In addition, babies who were born early have a greater risk of oxygen desaturation, apnea, and bradycardia than full-term babies. The semi-reclined car seat position can increase the number of episodes that preemies may have.

What Happens During a Car Seat Test?

During the car seat test, a premature baby is securely fastened into a car seat. The baby's own car seat should be used whenever possible. The car seat will be placed at the correct angle for riding in the car, and the baby will be buckled into the car seat just like he or she would be during an actual car ride. Regular NICU monitors will be used to measure the baby's heart rate, breathing, and oxygen saturation during the car seat test. If the baby will be going home with an apnea monitor, that monitor may be used instead.

A car seat test should last for at least 90 minutes. If the baby has no episodes of apnea, bradycardia, or desaturation during the car seat test, then he has "passed" the test.

If a baby fails the car seat test, then the test will be repeated after a few days have passed. Babies who fail the car seat challenge repeatedly may need to ride in a car bed, a type of car seat that allows them to lie flat while riding in the car.

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