Car Seat Safety for Premature Infants

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

Car seat safety is extra important for premature infants, who can be so small that they barely fit in a car seat. They can also have respiratory problems that make it hard for them to breathe well while sitting in a car seat. You can help keep your preemie safe in the car by choosing the right car seat and positioning your baby in it correctly.

Best Car Seats for Preemies

Choosing the right car seat is one of the most important steps in ensuring car seat safety for your premature baby. 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. This option can be used rear-facing for infants and older babies, then front-facing for toddlers. Convertible car seats don't have handles, which means that they can't be used as infant carriers. However, they can be used through infancy and toddlerhood, which can help you save money.
  • An infant carrier. These car seats are for infants only. Infant carriers have a handle and come with a base that is secured into the car. This means that the seat can be easily removed to carry the baby.

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.

You'll 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.

Finally, make sure that you check the seat's 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. 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.

Here are some criteria a physical or occupational therapist will point out to you when positioning your preemie in a car seat:

  • Fit: 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 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 have not been tested with the car seat for safety.
  • 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 mid-chest level (about the level of the armpit).

Placement in the Car

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.

Rear-Facing Car Seats

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

The AAP recommends that all infants ride rear-facing until the age of 2 because studies have shown that extended rear-facing is much better at protecting babies from severe injuries.

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

Protecting 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. Once you get your baby home, there are steps you can take to make sure that they can breathe well in the car seat:

  • 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.
  • Wait an hour after eating. Try to wait about an hour after feeding time before getting in the car seat—especially if your baby has reflux. This will allow the feeding to digest and will help prevent regurgitation.

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, 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 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 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 should last for at least 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 a 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.

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