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First do no harm: re-evaluating routine car seat testing before discharge

Pediatric Research (2026)Cite this article

It has been 34 years since the American Academy of Pediatrics Committee on Injury and Poison Prevention and the Committee on Fetus and Newborn released their statement advocating for routine car seat testing prior to discharge of preterm infants.1 The placement of infants in a car seat at a thirty-degree incline was thought to place them at risk of airway compromise. While such infants would have demonstrated respiratory stability in a supine position in the days prior to discharge, what might happen when their angle of incline was decreased? The purpose of such testing was to minimize the risk following discontinuation of monitors and discharge to the community of unwitnessed hypoxemic and/or bradycardic events while traveling in this semi-recumbent position. Testing of infants in car seats (Car Seat Tolerance Screening or CSTS) revealed that approximately 4% of such infants would develop episodes of systemic oxygen desaturation and/or bradycardia.2 This risk was deemed unacceptable for discharge. The practice of testing all preterm infants born at <37 weeks' gestational age prior to discharge became the standard of care following the release of this statement. Centers across North America quickly adopted this recommendation, and the practice became standard of care for the next twenty-five years with little question.

In 2016, the Canadian Pediatric Society Fetus and Newborn Committee published a statement questioning the utility of the CSTS.3 The argument against such testing included the low confidence in a pass or fail, as in both cases approximately 10% of such infants would have the opposite result if the test were performed shortly thereafter. Additionally, examining large collections of autopsy data failed to find patients who had died while in a car. Rather deaths in car seats predominantly occurred when infants were left in car seats to sleep after removal from the car. Following the publication of this statement, the practice of screening with CSTS prior to discharge largely vanished from the Canadian landscape, yet the practice has persisted in the United States.

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References

  1. American Academy of Pediatrics Committee on Accident and Poison Prevention. Safe transportation of premature infants. Pediatrics 87, 120–122 (1991).

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  1. Rady Faculty of Health Sciences, University of Manitoba, Department of Pediatrics, Winnipeg, MB, Canada

    Michael Narvey

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  1. Michael Narvey
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Correspondence to Michael Narvey.

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Narvey, M. First do no harm: re-evaluating routine car seat testing before discharge. Pediatr Res (2026). https://doi.org/10.1038/s41390-026-04818-7

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