Car Seat Safety for Premature Babies: How to Manage Safety Properly?

Nothing brings joy as welcoming a baby into the world! However, if your baby arrives sooner than expected, you need to know everything about car seat safety for premature babies.

Premature babies must undergo a car seat test before they are released from the hospital, leaving parents to wonder:

What is a car seat test, and what happens if my baby fails it?

This guide will take you through all the necessary details of a car seat tolerance test and how to adequately use a car seat with preemies.


What is a Car Seat Test for Premature Infants?

A car seat test for premature babies is conducted in a hospital one week before the release. A preterm infant is tested for car seat tolerance during the car seat challenge, while the heart rate, oxygen level, and breathing are monitored.

The purpose of a car seat challenge is to observe the baby's breathing while in a car seat. While in a rear-facing seat, premature babies are at an increased risk of respiratory problems, apnea, bradycardia, and oxygen desaturation.

The car seat test is often performed with low birth weight infants whose airways are weaker in a semi-reclined position car seats offer. The doctor may even suggest riding with special medical equipment on the car ride home.

Car Seat Safety for Premature Babies

Who Are the Candidates for the Car Seat Test?

Candidates for the car seat test are infants that fall under the following criteria:

  • Premature birth at less than 37 weeks gestation
  • Babies with hypotonia or Down Syndrome
  • Low birth babies (less than 5.5lbs at birth)
  • Babies with micrognathia
  • Infants suffering from a heart condition (low heart rate)
  • Infants born with weak airways, oxygen deficiency, or decreased muscle tone
  • Infants who require oxygen supplements
  • Babies with temporary pauses in breathing

How is the Car Seat Test Conducted?

During a car seat test, a baby needs to be in a semi-reclined position in their car seat. Then, the nurse attaches a cardiopulmonary monitor and pulse oximeter to measure the heart's oxygen saturation and electrical activity. The total duration of the car seat challenge lasts between 90 to 120 minutes, as an average car ride time.

If the results don't show any signs of apnea, heart palpitations, or breathing failure, your baby has passed the test.

The car seat test should be done at least seven days before the hospital release. Before the car seat test, have your partner bring the rear-facing safety seat you intend to use. The infant car seats should not be expired or damaged. The rear-facing car seat's weight limit must be suitable for infants weighing less than 20 pounds.

What if Your Baby Fails the Test?

If the premature infant fails the car seat challenge, the nurse will repeat the procedure within 24 hours. Usually, if the car seat test is not successful after three attempts, it should be conducted in a car bed or a different car seat.

Health advisors will discuss with parents all the other possible transport options. One of the most reliable is a car bed that allows for a flat position instead of a semi-reclined position.

Car Seat for Premature Babies: How to Pick the Right One?

car seat safety for premature infants
  • Weight Limit: The best car seat for a premature infant has a weight limit that supports a baby weighing less than 5 pounds. In addition, the height limit of the safety seat should be around 17-19".
  • Head Padding: Make sure the infant carriers like this have removable head padding. Keep the baby's airway clear by avoiding head padding during the first few days or months. The large head padding can be helpful after the baby has reached a specific weight limit, but it could also push the baby's head to the chest.
    Avoid purchasing car seats with arm pads or abdominal cushions, which can cause injury in case of a sudden stop. 
  • Shoulder & Crotch Strap: The shoulder straps, chest clip, and crotch strap must fit a small baby. Look for shoulder straps with an entry point at least seven inches from the bottom of the seat, as recommended by Children's Hospital Colorado. Choose a car seat with a short crotch strap to prevent your baby from sliding down.

A safety seat for premature infants can be one of the two:

Convertible car seats or rear-facing infant car seats.

- Convertible car seats are an excellent long-term investment. A convertible baby's car seat will often have a low weight limit so they can be used right from birth.

But, here is the best part:

With convertibles, you won't have to worry about purchasing a separate car seat for your baby's toddler period. Convertible seats can be used for at least six years until it's time to get a new one.

- Infant car seats allow only a rear-facing position and are the safest car seat option for preemies. An infant carrier includes a carry handle on the top so you can easily carry your baby from the hospital to the car ride home.

Before leaving the hospital, consult with the staff if a certified child passenger safety technician is near you. If this is your first child, it's best to seek help from an expert when installing the car seat.

How to Make the Infant Car Seat Fit a Preemie?

Remember that even if a baby meets the weight and height requirements, the car seat may not fit entirely. So before you decide to adjust the rear-facing car seat by yourself, it's best to consult with a CPST first. 

Let's discuss how you can alter a regular infant car seat to fit your baby.

Use appropriate position aids

Position aids and other equipment can be beneficial. However, they are commonly misused. To keep the premature baby safe in the car seat, you must only use position aids that come with the car seat. Never use a blanket roll, a pool noodle, or other if the car seat manufacturer did not specify the use as suitable.

Position aids and head padding that you buy separately have not been tested with your car safety seats. Therefore, they do not allow the baby to ride safely. 

Consult with the car's manual

The car seat of your choice may not allow for some alterations, so it's best to consult with the manual first. Car safety seats have adjustable harness slots, a crotch strap, and shoulder straps that are adjusted according to the instructions.

Once your baby is ready to switch a car seat to a bigger side, consult with a technician about the transition. Not every rear-facing safety seat works the same, and you may need to test it out at home before using it in the car.

Adjust the harness

Once you safely position a baby in the rear-facing car seat, it's time to adjust the harness and crotch straps.

Both of the straps need to be able to fit a small infant without any looseness present. If you cannot pinch the harness straps together, it's a sign you have adjusted them perfectly.

How to Safely Position the Preemie in a Car Seat?

car seat safety for a premature newborn
  • The baby's back and bottom must be against the car seat's back.
  • Avoid head padding that pushes the baby's head to the chest.
  • Place the harness over the baby's shoulders and tightly adjust it.
  • Check the car seat manual on how to adjust the recline. Consult your pediatrician on the proper recline angle for small babies for this part. Most rear-facing car seats have recline indicators, so you reach the perfect position for preterm infants.
  • A rear-facing car seat must be in the back seat, never in the front passenger seat.

Is the Premature Infant Safe in the Car Seat?

A premature infant is safe in the car seat if you properly adjust the seat to the baby's body. These are a few guidelines to ensure your baby is safe in their seat.

Keep an eye on the baby

It's best to have an adult sit in the back with the baby's car seat. This way, optimal car seat safety is ensured while the driver keeps an eye on the road. In addition, if the baby needs adjustment, the person next to it can always quickly react. Therefore, even with full-term babies, having an adult in the back is recommended.

Limit car rides

Limiting the car ride is always best, even if you find the right car seat for premature infants. Preterm babies need to lie in a position that is comfortable for their stage. If not, preterm infants often find it hard to be in a position that fights against gravity as their muscle tone is not yet strong.

Infants who lie in one position for a long time can develop flat head patches. Plus, the nap time in the car seat should be kept at a minimum. Once you get home, take the baby out of the rear seat and put it in the crib or bassinet.

Adjust the baby's head

Preterm infants are at risk for oxygen desaturation. The baby's head can often slump down to the chest if not adjusted properly. This type of position can cause infants to have trouble breathing.

Traveling With Medical Equipment

Some convalescent infants in car seats will have to travel with apnea monitors, ventilators, or oxygen tanks. However, this medical equipment can quickly become dangerous during car rides.

The heavy equipment can become projectiles in a crash or sudden stop. Before leaving the hospital, check your vehicle for storage units. Often parents secure this medical equipment with the vehicle's seat belt that is not in use. Other alternatives are using soft pillows or bungee cords.

If you have a long ride ahead, ensure the equipment has enough battery power.

What Are Car Beds?

If your baby fails the car seat challenge, the medical staff will recommend using car beds instead. Car beds are suitable for babies that need to be lying in a flat position instead of a semi-upright position.

Babies with a high risk of apnea or oxygen desaturation need to ride in a car bed. However, the AAP recommendations say that babies weighing heavier than 4 pounds can tolerate a semi-upright position and ride in a car seat.

Many parents wonder:

Is a car bed safer than car seats?

A baby's car bed can only do so much protection in case of a crash. Special car bed lacks support and side impact protection, so they cannot protect your baby in case of a side, rear, or frontal crash.

Unlike car seats, a car bed is made from soft materials without any reinforcement. A car seat shell of the rear seat is designed to absorb all of the crash force without compromising your baby's safety.

If your baby needs to ride in the car bed, it's best to limit the car rides. Instead, take frequent stops every 90 minutes and take the baby out of the car bed for a quick rest.


Do preemie babies need a special car seat?

Preemie babies do not necessarily need a special car seat. Since preterm infants are not released from the hospital until they reach at least five pounds, you can use any rear-facing car seat designed for small babies. The best car seat choices for a preterm infant are convertible and infant car seats.

Infant car seats can be altered to fit a preterm infant by adjusting the harness and crotch straps. In addition, some seats come with an infant insert or a head padding. However, you can only use the ones with your car seat model and never purchase aftermarket products.

Why do they do a car seat test for preemies?

A car seat test or a challenge is conducted to check whether preterm infants can sit in a car seat without suffering respiratory or cardiac problems. Infants born 37 weeks gestation are at high risk of apnea, bradycardia, and oxygen desaturation.

Since a semi-recline position of a car seat can oppose a threat to the baby's airways, car seat challenges are necessary for checking tolerance. A baby can either pass or fail the car seat challenge. In case of a failed test, a baby should be tested in a different seat or a car bed.

Do preemies have to pass a car seat test?

Preemies do have to pass a car seat test to be able to ride in a car seat. If a baby passes the car seat tolerance test, the medical staff will inform parents of the proper use of the infant seat.

However, if the preemie does not pass the test, then the test is repeated in the next 24 hours. After three failed tests in a car seat, the challenge can be done in a different car seat or a car bed.

How long can a preemie be in a car?

A preemie infant should not be in a car seat for more than 90 minutes. If the car ride is more than 90 minutes, you should make pit stops and take the baby out of the safety seat for a little while.

Once you get home, a baby should sleep in its bed, never in the safety seat!

When can you travel with a premature baby?

Traveling with a premature baby should be discussed with your pediatrician first to check whether a baby is ready for long travels. Since there are no official guidelines for traveling with a preterm infant, it's best to wait at least 3-6 months for air travel.

Preterm babies are at high risk of breathing complications, and air pressure in the cabins can often oppose a threat to their health.

What is the minimum weight for a car seat?

The minimum weight for a car seat is 4 lbs (1.8 kgs). Premature babies can use a rear-facing car safety seat with appropriate harnesses and padding.

Are newborn inserts for car seats safe?

Yes, newborn inserts that come with the car seat are safe. However, parents should avoid using aftermarket inserts incompatible with their car seats. Second-hand inserts are not crash-tested with your car seat and can cause more damage than good if misused.

Final Words

Premature babies require special care upon their hospital release. However, with these helpful guidelines, you will conduct car seat safety with no problem!

We hope we have answered all your dilemmas on car seat safety for premature babies so you can prepare for the car ride home.

Avatar of Kathy Warner

Kathy Warner

Kathy is a busy mother of two and a CPS technician for more than eight years. Her mission is to awaken parents to the importance of child passenger safety and show them the right practice. You can read more about her here

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