Car seat safety for preterm neonates: implementation and testing parameters of the infant car seat challenge

Acad Pediatr. May-Jun 2013;13(3):272-7. doi: 10.1016/j.acap.2013.01.009. Epub 2013 Feb 1.


Background: The American Academy of Pediatrics (AAP) recommends that all preterm neonates undergo a period of observation in a car safety seat before discharge, known as the Infant Car Seat Challenge (ICSC), to monitor for respiratory immaturity and the risk of adverse cardiopulmonary events in the upright position. However, no universal guidelines exist to define appropriate cutoffs for failure of the ICSC. We sought to evaluate regional neonatal intensive care unit (NICU) implementation of the ICSC and to evaluate variation in failure criteria.

Methods: We contacted level II and III nurseries/NICUs in New York/New England (n = 119) to determine if each performed ICSCs, their inclusion criteria, duration of testing, and failure criteria.

Results: We contacted 119 institutions and had an 87% response rate (n = 103). Of the institutions that responded, 89% (n = 89) perform ICSCs. Of these 89 with current protocols, 17% did not follow AAP guidelines to test all neonates born <37 weeks' gestation, and 45% did not follow guidelines for test duration. Despite wide variation, most units use thresholds for bradycardia of <80 bpm and desaturation of <90% to determine failure.

Conclusions: Despite AAP guidelines, implementation of ICSCs for preterm neonates is not universal in the region studied. Variation in definition of ICSC failure means that neonates are receiving differential care, not on the basis of their clinical characteristics, but on which institution performs the test. We propose standardizing the test to all infants born at <37 weeks' gestation to a duration of at least 90 minutes, along with a failure threshold for bradycardia of <80 bpm for >10 seconds, and for saturation <90% for >10 seconds.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Apnea / etiology
  • Apnea / prevention & control
  • Bradycardia / etiology
  • Bradycardia / prevention & control
  • Child Restraint Systems / adverse effects*
  • Guideline Adherence / statistics & numerical data
  • Humans
  • Hypoxia / etiology
  • Hypoxia / prevention & control
  • Infant, Newborn
  • Infant, Premature
  • Intensive Care Units, Neonatal / statistics & numerical data
  • Monitoring, Physiologic
  • New England
  • New York
  • Patient Discharge
  • Posture / physiology*
  • Practice Guidelines as Topic / standards*
  • Reference Values
  • Respiratory Mechanics / physiology*