Car Seat Safety for Premature Babies

Best car seats for preemies and how to use them safely

Premature baby in car seat getting oxygen
Jill Lehmann Photography / Getty Images

Preemie car seat safety is extra important. Premature babies can be so small that they don't fit well in or meet the minimum weight for an infant car seat. Preemies can also have respiratory problems that make it hard for them to breathe well while sitting in a car seat.

Before your baby can leave the hospital, healthcare providers will perform a car seat test to determine if your baby can safely ride in a car seat. For babies that cannot safely ride in a car seat, they may need to stay in the hospital a little longer. Or, doctors may recommend they travel in a special car bed.

You can help keep your preemie safe in the car by knowing how to safely use a car bed or choosing the right car seat and positioning your baby in it correctly. Here is what you need to know about preemie car seats and car beds.

Car Seat Tests for Preemies

The car seat test checks that premature babies are able to sit in a car seat safely, without any episodes of desaturation, apnea, or bradycardia (breathing or heart rate problems). 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 (AAP) 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, they will need to grow a little bigger before having the test repeated. Some babies who are unable to pass the car seat challenge might need to ride in a car bed for safety.

Premature babies can 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 they 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 they 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 typically lasts for 90 minutes. If the baby has no episodes of apnea, bradycardia, or desaturation during the car seat test, then they have "passed" the test.

If your baby fails the car seat test, it can be repeated in 24 hours at the earliest. 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.

How to Use a Car Bed Safely

If your baby does not do well in the car seat challenge, or if they have other medical conditions that prevent them from going home in a traditional car seat, you may be advised to use a car bed. Car beds allow babies to lie down while traveling. This is sometimes necessary for babies who have trouble breathing in a semi-reclined position.

Only use and install a car bed if your baby's healthcare team recommends its use. Then, it is important to follow the manufacturer’s instructions for your baby's car bed. The car bed should be placed in the rear seat so that your baby’s head is in the center of the vehicle, away from the door.

To secure the bed in your car, you will use the vehicle's seatbelt. You will need to make sure the belt is tight. When using the bed, place your baby on their back, unless your baby's provider has instructed otherwise.

While your baby is in the car bed, another adult should ride in the back to watch them. The driver should not be tasked with watching the baby. If your baby needs a breathing monitor or other equipment during the car ride, make sure you learn how to secure it so that it does not move or fly around in case of a sudden stop or crash.

If your baby must ride in a car bed, you should limit the number of car rides you take and avoid taking long trips until your baby is able to switch to a traditional car seat. If you have to be in a car for longer than three hours, you should plan for rest stops every two to three hours so that you can get your baby out of the bed, care for them, and feed them.

If your baby goes home on a monitor, make sure you have enough battery power for at least twice the length of your car ride. In other words, if your baby will be in the car for one hour, you will need two hours of battery power.

How to Choose the Best Preemie Car Seat

If your baby's healthcare provider determines it is safe for your baby to go home in a car seat, choosing the right car seat is an important step in ensuring your preemie's safety. Many preemies will go home below the lower weight limit for many car seats. Therefore, you will need to choose a seat that will properly fit a small baby.

There are two types of car seats that you can choose from—a convertible car seat (suitable for babies, toddlers, and preschoolers) or an infant carrier. 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. Pick an infant car seat with a space of 5-1/2 inches or less between the crotch strap and the back of the seat. 

You will also want to look for a car seat with a crotch strap or buckle position that can be adjusted to be snugger and fit a smaller baby. Also, make sure that you check the seat's weight minimum. Many car seats will fit babies as small as 4 pounds, so you should get one of those if you can.

Keep in mind, too, seats with a curved back or large head padding can push your baby’s head toward their chest and close their airway. If you cannot adjust the car seat to keep your baby’s airway clear, you may need to find a different car seat.

You also should avoid extra padding that keeps your baby from moving. Although you want your baby to be snug, they should still be able to move their arms and legs as well as turn their head. If the padding is too close to their head, they could turn their head and suffocate in the padding.

How to Position Your Preemie

Choosing the right car seat is only the first step in car seat safety for preemies. It's also essential that you correctly position your premature infant in the car seat.

If your baby is small at birth or born premature, you might be scheduled for an appointment with an occupational or physical therapist. They will help you learn to safely position your baby in a car seat.


If your baby does not fit securely in your car seat with the straps at their smallest settings, your physical therapist might show you how to use blanket rolls and a washcloth to improve the fit. However, only do this if a healthcare professional 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 (unless as directed by a healthcare professional), as they have not been tested with the car seat for safety. They also can move around and obstruct your baby's breathing.

Straps and Harness

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 mid-chest level (about the level of the armpit).

How to Protect Your Preemie's Airway

Premature babies might have breathing problems that can make it hard for them to breathe well in the semi-reclining car seat position. There are steps you can take to make sure that they are safe in their car seat and that their breathing is not affected during a car ride.

Monitor Them

Have an adult ride in the back seat with your baby. Until they are able to maintain a good position in the car seat, it is safest to have an adult ride with them. If your baby begins to slouch or spits up milk, that person can reposition or suction them if needed.

Limit Car Rides

Take car rides only when necessary and try to make sure your trips are short. During the first few months of life, car trips should be limited and not more than an hour—preferably shorter. If you must be in the car for longer periods of time, stop for rest breaks frequently.

Wait an Hour After Eating

Try to wait about an hour after feeding time before putting your baby in the car seat—especially if they have reflux. This will allow the feeding to digest and will help prevent regurgitation.

A Word From Verywell

If your baby was born prematurely, you have probably been waiting for a while to bring them home. But leaving the hospital is not as simple as putting them in the car and heading out. Instead, they must have a car seat test so that their healthcare team can determine the safest way for them to travel. Sometimes that is in a car bed and sometimes that is in a traditional car seat.

No matter what method of travel they recommend, be sure your follow the healthcare providers' recommendations on travel. With the proper precautions, you should be able to keep your baby safe in a car.

Finally, until they can sit in a car seat without any breathing challenges, you should limit their car rides. This time period should not last too long. Before you know it, your baby will be ready to enjoy getting out more.

6 Sources
Verywell Family uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. Mandell L, Rhein LM, Feldman HA, Bergling E, Porter C, Degrazia M. Predictors of persistent infant car seat challenge failure. Adv Neonatal Care. 2017;17(6):499-508. doi:10.1097/ANC.0000000000000432

  3. Children's Hospital of Philadelphia. Car seat safety: Premature babies and babies with medical conditions.

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By Cheryl Bird, RN, BSN
Cheryl Bird, RN, BSN, is a registered nurse in a tertiary level neonatal intensive care unit at Mary Washington Hospital in Fredericksburg, Virginia.