What if I have a Preemie or Small Newborn?

Low 1st shoulder strap slot. The closer the shoulder strap slots are to the baby’s shoulders, the better. It is best to have the straps start BELOW the baby’s shoulders when the baby is rear-facing. With preemies and even newborns, it is usually not possible to have the straps start below the shoulders, but getting a seat where the strap slot is as close as possible is important.

Close crotch buckle position. The farther the crotch buckle is from the baby’s body, the more the baby is likely to slouch. Slouching is dangerous as the head is likely to fall into a chin-to-chest position when the baby slouches.

Short crotch buckle. If the crotch buckle is too long, you run into a situation where you can’t fit the chest clip + crotch buckle on the tiny baby’s chest and the chest clip ends up pushed into the child’s throat or across the face… which is obviously not going to work! Some seats allow you to J-loop the crotch buckle which allows you to shorten it for the smaller babies.

Narrow spacing between the leg straps. The closer the leg straps are to the sides of the baby’s body, the better the fit.

Seat design that allows baby’s head to rest farther back than baby’s chest. A well designed infant insert is one that pushes the baby’s back and shoulder blades forward, such that the baby’s head can rest farther back than the rest of the body – as this will do the most to ensure that the baby’s chin stays off his chest. 

There are still quite a few infant seats (also called rear-facing-only seats) that start at 5 pounds, but the good news is that there are tons of these seats that start at 4 pounds. The Combi Shuttle is the only infant seat that has no weight minimum.

Infant Seats with a 4 lb. Minimum

BABY JOGGER – cityGO

BABY TREND – call their customer service for a free foam wedge that can be used with some of their infant seats to allow a 4 pound starting weight

BRITAX – B-Safe 35, 35 Elite

CHICCO – Fit2, Key Fit (all models)

CYBEX – Aton, Aton2, AtonQ, CloudQ

Note: Of the Cybex seats, the Aton2 will fit small babies the best.

EVENFLO – Embrace, LiteMax, SafeMax ICS, Snugli ICS

GRACO – all Snug Ride Click Connect models (including all SnugLock models)

For all Graco infant seats with a no-rethread harness (seats where the structural head rest moves up/down and adjusts the height of the shoulder straps with it) the crotch buckle can be J-looped to give a better fit for a small baby.

MAXI COSI – Mico Max 30

MOUNTAIN BUGGY – Protect

NUNA – Pipa

PEG PEREGO – Primo Viaggio 4-35, Primo Viaggio 4-35 Nido

RECARO – Performance Coupe

SAFETY 1st – Light N’ Comfy, onBoard 35 (all models, including Air)

SIMPLE PARENTING – Doona

UPPABABY – Mesa

URBINI – Sonti

(list last updated 4/17)

What is a Car Seat Test?

A car seat test, often called an “angle tolerance test” is where a baby is strapped into a car seat for 90 minutes while hooked up to a monitor that can make sure the baby maintains his heart rate, breathing rate, and oxygen level during the test.

Who should get a Car Seat Test?

The American Academy of Pediatrics recommends that all babies born before 37 weeks and those weighing less than 2500g get a car seat test before going home from the hospital. Other babies who should get a car seat test are those who are:

• Going home on an apnea monitor
• Going home on oxygen
• Known to have craniofacial deformities–like Pierre Robin sequence–that may make it harder to breathe in a semi-upright position
• Considered to be at increased risk — by the pediatrician or other members of the healthcare team — of not tolerating a semi-upright position.

During the car seat test (often called an “angle tolerance test), the baby will sit properly strapped into her car seat for 90 minutes to make sure that her heart rate, breathing, and oxygen levels stay in a normal range. The semi upright postion of the rear-facing car seat is a stressful position for a baby, compared to laying flat. A baby “fails” the test if her heart rate drops (bradycardia) OR her oxygen level drops (desaturation) OR she stops breathing (apnea).

What if my baby passes the car seat test? The AAP recommends that babies who “pass” their car seat test go home in a rear-facing car seat.

What if my baby fails the car seat test? Babies who “fail” their car seat test may be retested in their car seat in another day or two to see if they pass. Babies who continue to fail their car seat test should not be automatically sent home in a car bed; rather, they should have a “car seat test” in the car bed to see if the apnea, bradycardia, and/or desats continue to occur in the car bed, or if the car bed seems to resolve the problem. If a baby is discharged home in a car bed, there should be a plan in place for retesting the baby in the future so that the parents know when it is safe to transition back to a regular car seat.

Car beds should only be used for infants who “fail” the car seat test – i.e. they can not maintain their heart rate, oxygen level or breathing rate while in the rear-facing car seat – as the protection provided by a rear-facing car seat is better documented than that for car beds.

Buckle the baby into the safety seat exactly as you would if they were to ride in the car. Make sure the straps are properly snug, the baby is not slouching, and that nothing is added to the car seat that didn’t come with the car seat (i.e. no infant positioners, pillows, etc,). You may however put receiving blankets alongside the baby’s head and body to provide extra support if you’d like.

Once the baby is buckled in snug, we recommend swaddling them (over top of the straps, of course) as this will help the baby sleep through the 90 minute car seat test.

Make sure the car seat is as reclined as the manufacturer allows. All infant carriers have an angle indicator – typically a line on the side of the carrier that when the line is parallel to the pavement/floor, the carrier is as reclined as it is allowed to be in the vehicle. Use this line to make sure the carrier is reclined properly in the hospital’s car seat test.

Wait at least 30 minutes after a feed to do the test.

Car beds are for use only by babies who have a medical need to lay flat. According to the American Academy of Pediatrics, a baby (even a 4 pound preemie) who can tolerate sitting in a semi-upright position should ride in a rear-facing safety seat, not a car bed. A car bed is a safe option for babies for whom there is no other option. A rear-facing safety seat offers better protection than a car bed for a baby who can tolerate sitting semi-upright. Rear-facing safety seats have an excellent track record in all real world crashes of providing the best protection in any type of crash. In a rear-facing safety seat, the shell of the safety seat does a tremendous amount to absorb the crash forces and distribute them on the strongest parts of the baby’s body–the baby’s entire back. A car bed’s shell is not able to do as much, especially in a side impact. Babies who fail the car seat test and leave the hospital in a car bed should have a plan in place for when they will be retested in a rear-facing safety seat.

Angel Guard Angel Ride Infant Car Bed

• From birth (there is no weight minimum) up to 9 pounds and 21.5 inches.
• Takes up 1 seating position and is relatively easy to install.
• Allows child to ride prone, supine, or side-lying

Cosco Dream Ride SE

• From 5-20 pounds
• Takes up 2 seating positions (requires a bench seat) and is typically difficult to install securely with a seat belt – but installs quite easily with LATCH.
• Allows child to ride prone or supine.

Hope Car Bed

• From 4.5 – 35 pounds
• Takes up 2 seating positions (requires a bench seat)
• Allows child to ride prone, supine, or side-lying
• Comes with a variety of restraint types including a 5 point harness as well as a bunting. This is designed for children with medical needs that require a car bed for an extended period of time, as well as those who can not tolerate a harness (and can use the bunting) – such as those with severe osteogenesis imperfecta. Babies with an unrepaired giant omphalocele who can not tolerate the semi-upright position of the Jefferson will be well-suited in the Hope car bed using the bunting bag. 

Some children must travel with devices such as apnea monitors, oxygen tanks and ventilators.

Secure these devices in the vehicle so that they do not become flying objects in a crash or sudden stop. At this time, there is no single product available to secure medical devices. Try securing the equipment with seat belts not being used by other passengers. If it is not possible to secure the equipment with a seat belt, try wedging the equipment on the vehicle floor with pillows.

Make sure that any devices that use batteries have enough power for your entire trip.