Car Seat Safety: Premature Babies and Babies With Medical Conditions

Even with the best prenatal care, sometimes your baby wants to arrive a little earlier than planned. If this happens, your hospital will want to make sure your baby can travel safely in the car. Usually, infants born earlier than 37 weeks will need a tolerance test, also known as a car seat test. Babies with other medical conditions or those who may not tolerate sitting in a semi-reclined position, such as a rear-facing car seat, may also need this test.

Car seat test

Car seat testing is usually done in the hospital within one week before your baby is ready to go home. You will be asked to bring in your baby’s car seat, which he will sit in for 90 to 120 minutes or the length of the car ride home, whichever is longer. During the test, the nurse will monitor your baby’s heart rate, breathing and oxygen level.

If your baby passes the car seat test, he will be able to use the car seat you have provided. If not, the hospital may repeat the same car seat test.

If your doctor tells you that your baby needs a car bed, it is likely because of concerns with your baby’s breathing and heart rate when he’s semi-reclined in a traditional child safety seat. The doctor may also order a home monitor to check your baby’s heart rate and breathing.

Car beds

Medical staff may require your infant to ride in a car bed rather than a traditional child safety seat. Car beds allow babies to lie down while traveling. The American Academy of Pediatrics (AAP) recommends that medical staff monitor infants with the following indicators before their first car trip:

  • Infants less than 37 weeks gestational age at birth
  • Infants of any age who may not tolerate sitting in a semi-reclined position, such as a rear-facing car seat
  • Infants at risk for apnea, bradycardia, oxygen desaturation or obstructive apnea (e.g. Pierre Robin Sequence)

Your pediatrician may repeat the car seat test to find out if your baby is medically stable enough to use a car seat.

Car bed safety tips

Please follow the manufacturer’s instructions for your baby's car bed and these guidelines:

  • 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.
  • Use the vehicle’s seat belt to attach the car bed to the vehicle and be sure that the belt is tight.
  • Place your baby on his back, unless otherwise instructed by your doctor. If your baby’s pediatrician recommended placing your baby on his abdomen while riding in the car, she should tell you when this is no longer medically necessary.
  • If your baby needs a breathing monitor or other equipment, learn how to secure it properly to prevent it from moving if a crash should occur.
  • While your baby is riding in a car bed, someone other than the driver should watch him.
  • Limit car rides, especially long trips, until your baby is medically stable enough to switch to a car seat. If the car ride will be longer than three hours, allow for rest stops every two to three hours so your baby can be out of the car bed for feeding and care.
  • Avoid using baby seats, baby swings, bouncy chairs, backpack slings and infant carriers until your baby is re-tested or your pediatrician says that it is safe for him to be in a semi-reclined position.

If you still have concerns about installing and using the car bed properly, you can visit a car seat fitting station nationally or in the greater Philadelphia area. Please visit Car Seat Checks to learn more.

Tips for using a traditional child safety seat

If your pediatrician determines that it is safe for your baby to be in a semi-reclined position, follow these tips to safely position your baby in a traditional safety seat:

Rear Facing Child Safety Seat with Blanket Rolls Image

  • Make sure you check the weight requirements on the car seat and that your baby weighs enough to use the seat.
  • Infant-only car seats with three- or five-point harness systems or convertible car seats with five-point harness systems provide the best comfort and positioning for your baby.
  • Do not use a car seat with a shield, abdominal pad or arm rest because it may cause breathing problems for your baby or may cause an injury to your baby’s face and/or neck during a sudden stop or crash.
  • Only use head supports that come with the car seat. Do not use any head supports that are purchased separately. Most very small babies may need additional positioning support; you can put a blanket roll on each side of your baby to provide support for her head and body.
  • When choosing your car seat, select one with the shortest distance from the crotch strap to the seat back. This will prevent your baby from moving forward under the harness.

Photo caption: A properly positioned baby in a rear-facing child safety seat with a blanket roll on each side and at the crotch strap, if the manufacturer allows

Positioning your baby in the car seat

  • Your baby should be properly positioned in the car seat, with his buttocks and back against the back of the car seat. The harness must be snug and remain at or below his shoulders while rear-facing. The retainer clip should be positioned in the center of your baby’s chest, not on the abdomen or in front of the neck.
  • Infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for two years or more.
  • Recline the rear-facing car seat according to the manufacturer’s instructions. Most car seats have built-in indicators and angle adjusters to help you set the proper angle. Follow the instructions provided with the car seat. A lightweight, very firm object, such as a tightly rolled blanket or pool “noodle,” may be placed under the car seat to create the correct angle if the manufacturer allows.
  • Never place a rear-facing car seat in the front passenger seat.
  • It can be difficult to see your baby while driving. Whenever possible, have an adult sit in the rear seat next to your baby.

For help installing a car seat, visit a community child safety seat inspection station. Updated inspection station information can be found at

Additional equipment

  • If your baby goes home on a monitor, make sure to have enough battery power for at least twice the length of your car ride. If you are taking a one-hour ride, you will need two hours of battery power.
  • Secure any portable medical equipment to reduce the risk of it flying loose in a crash or sudden stop.