Taking your baby home from the neonatal intensive care unit (NICU) is one of the most exciting days in a new parent’s life, and one of the first things you might think about is getting your car seat ready. This is especially important for families with a premature baby or a baby with complex medical conditions.

Premature babies are smaller, more fragile and may face breathing challenges while riding in the car. Choosing a car seat and knowing how to use it can help your baby’s health and safety needs. Our certified child passenger safety experts from Children’s Hospital Colorado’s safety store share tips to help you choose the right car seat and position your baby safely so you can focus on celebrating your baby’s homecoming.

Choosing the best car seat for premature infants

When choosing a car seat for a premature infant, look for one that fits babies as small as 3 to 4 pounds and 17 to 19 inches tall. Many car seat manufacturers now offer models that are specifically designed with premature car seat inserts and extra safety features. Read the car seat manual and your car’s instruction manual to check for any special considerations.

Here’s what to consider:

• Strap position: With shoulder straps, less is more. If you get a car seat designed for smaller babies, everything should be safe and sound
• Flat back design: Look for a flat-backed seat. This helps keep your baby in a safer position.
• Minimal head padding: Avoid bulky or fixed head padding that could push your baby’s head forward and block their airway. 

You’ll likely choose between two types of car seats:

• Convertible car seats: These grow with your baby, transitioning from rear-facing to forward-facing as your baby grows. Some models are safe for premature babies.
• Rear-facing car seats: These have removable bases and are designed for newborns only. They’re the most common choice for premature babies due to their size and reclining options.

A certified car seat safety technician can help you install the seat and make sure it fits your baby properly before leaving the NICU. Even if the measurements seem right, a seat may not fit your baby when the time arrives. A certified technician can make sure your baby is safe and comfortable before you go home.

Infant positioning: Premature head position in car seats

Premature babies are vulnerable to airway blockage caused by poor positioning in a car seat. Before leaving the hospital, ensure your newborn’s head position prevents slumping forward.

How to adjust car seat straps and position your baby safely:

• Keep your baby’s head in line with their spine, and not leaning forward.
• Use the most reclined setting your car seat allows.
• Position shoulder straps below your baby’s shoulders and tighten so you can’t pinch any extra straps.
• Make sure the chest clip is at your baby’s armpit level.
• Only use positioning aids that come with your car seat or were approved by the manufacturer.
• Do not use improvised padding or rolled blankets for positioning.

What is a car seat tolerance screening?

Before discharge, your NICU care team may perform a car seat tolerance screening (sometimes called a car seat safety test). During this test, your baby will be monitored for oxygen levels, heart rate and breathing while sitting in their car seat — usually for 90 minutes or longer.

If your baby doesn’t pass the test, your care team may try again after a short amount of time. In rare cases, your doctor may also recommend a premature infant car bed instead of a car seat. A car seat bed allows your baby to lie flat, which may be safer if they have certain medical conditions. You should only get car beds from the hospital or your care team.

How to adjust a car seat for a premature baby

If you’re wondering when or how to adjust car seat straps , here are a few quick guidelines:

• Always check the car seat manual for strap and buckle positioning based on weight.
• Adjust harness straps so they are at or below the baby’s shoulders.
• Tighten the harness so that there is no slack at the hips and it fits snugly so you cannot pinch the material over the baby’s shoulders. The chest clip should be at armpit level.
• Don’t switch to the next car seat stage (such as forward-facing) until your baby exceeds the height or weight limits of the current use of the seat (like rear-facing limits).
• If you’re unsure, consult with a certified technician.

Experts recommend that babies remain rear-facing for as long as possible. Colorado law says that children under 2 who weigh more than 40 pounds or who are between 2 and 4 and weigh at least 40 pounds can sit forward-facing but must be restrained to some type of car seat until age 9.

How long can a baby stay in a car seat?

Premature babies or babies with medical conditions should not stay in a car seat longer than 90 minutes at a time. Long car rides should be broken up with stops where you take your baby out of the seat completely. Extended time in a car seat can affect an infant’s breathing.

Additional tips:

• Place your baby’s car seat in the position (left, middle or right) where you can most securely install it as shown in your car seat’s manual. No one position is necessarily safer than another.
• Keep their naps in the car seat short while driving, and don’t let them sleep in their car seat once you get home. Setting the car seat on the ground can change its angle, which could block your baby’s airway.
• Babies in car seats shouldn’t be placed in cribs, in shopping cart baskets or on elevated surfaces.
• Babies should always be buckled whenever they are in their car seat.

When in doubt, talk to a child passenger safety technician. The time you take will be worth it for your child’s safety — and your peace of mind.

Securing medical equipment during travel

If your baby is going home with oxygen, a heart monitor or other equipment, keep car seat safety in mind. This equipment could become dangerous in the case of a crash. Secure devices using seat belts in an unused seat, as if it’s a passenger. Loop the belt through a handle or anything else that can help secure it. If no seat is available, place devices low on the floor and secure it with hook-and-loop fastener straps or other straps. You can also secure items under the front seats with a rolled blanket or towel if that works in your particular vehicle. If you have questions about car seat safety with equipment, talk with a child passenger safety technician or consult your NICU care team.

Final car seat safety checklist

Before your baby’s first ride, double-check the following:

• Straps are snug and chest clip is at armpit level.
• Their head is in an upright position and the airway is clear.
• The car seat is installed securely with the correct recline.
• You’ve completed a car seat safety test if required.
• All medical devices and equipment are secured.
• You’re using the correct premature baby car seat or infant car seat bed, if needed.