CAR
CAR SEAT MONITORING
Department NICU, Pediatrics
PURPOSE To outline the nursing role and responsibility regarding car seat
monitoring prior to discharging a baby from the NICU/SCN/ Pediatrics who was born
less than 37 weeks gestation.
POLICY
The American Academy of Pediatrics (AAP) recommends that preterm
infants less than 37 weeks gestation should have an observation period in a car safety seat
before hospital discharge in order to monitor for possible apnea, bradycardia or
desaturations. Therefore, all infants less than 37 weeks gestation at birth and are admitted
to the NICU/SCN, or any infant identified by the physician, will have Car Seat
Monitoring provided prior to discharge.
Infants with documented desaturation, apnea, or bradycardia in a semi-upright position
should travel in a supine or prone position in a car bed that meets or exceeds federal
safety standards.
EQUIPMENT
 Pulse oximeter
 Cardiac monitor
 Car Seat Challenge Flow Sheet (see attachment)
 Car seat
 Car seat base as appropriate
 Positioning supports (optional)
PROCEDURE
1. Obtain physician order for car seat monitoring.
 Conduct test within 7 days prior to discharge. However, if there is no definitive
change in the patient’s condition or stability, a successful test does not need to be
repeated, even if the discharge date is extended.
 Observation period should begin 30 minutes from the last feeding.
2. Place a 3 or 5 point harness system car seat on appropriate surface. Position car seat at
a 45-degree angle during the trial period, utilizing base if car seat comes with base.
 Utilize patient’s car seat for trial. If not available, obtain seat from social services.
 Seats with a distance of 10 inches or less from the lower harness strap to the seat
bottom should be selected to reduce the potential of harness straps crossing the
infant’s ears.
 If utilizing a seat with a base, the seat must be in the base for the testing period.
3. Place infant in the car seat dressed in an outfit that allows access between the legs.
• Do not wrap the infant in blankets or heavy clothing before placing in the car seat.
• A blanket can be placed over the baby after securing them in the seat.
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4. Make sure infant's buttocks and back are flat against the back of the car seat.
5. Apply harness so that straps are at or below the shoulder level. The harness retainer
clips should be level with the infant's armpits or midpoint of the baby's chest. Make
any adjustments necessary so that infant fits snugly into the car seat.
• The harness should fit over the shoulders and hold the infant in the seat.
• Harness straps should lie flat and snug against the infant's body.
• NEVER place extra cushioning under or behind the infant. This prevents the
harness straps from being snug.
6. Properly support infant's head in the midline position.
• Rolled blankets or cloth diapers can be used on either side of the infant for support.
• You may also place a rolled diaper or wash cloth between the infant's diaper area
and the crotch strap to keep the infant from slipping down.
7. Place infant on cardio-respiratory and pulse oximetry monitors. Obtain baseline
assessment to include: heart rate, respiratory rate and effort, oxygen saturation, color
and state (quiet awake, crying, etc.).
8. Monitor infant for 60 minutes. Leave infant undisturbed for 60 minutes.
9. Document baseline parameters as identified on Car Seat Challenge Flow Sheet every
20 minutes. Identify episodes of:
 Desaturations less than or equal to 85% for a period of greater than or equal to 30
seconds
 Bradycardia less than 80 beats per minute
 Apnea greater than 20 seconds
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 Color changes
 Any necessary interventions
10. Return infant to his/her crib at the conclusion of the study.
11. Car seat challenge will be discontinued/assessed as FAILED with the following infant
parameters:
a. Bradycardia less than 80
b. Apnea greater than 20 seconds
c. Persistent labored respirations
d. Dusky color accompanied by pulse oximetry readings of less than 85 percent for
greater than or equal to 30 seconds.
12. If patient fails after first test, retest no sooner than 1 hour.
• Usually wait 6-12 hours.
13. If failure occurs after 2nd test, notify M.D.
14. If physician orders car bed, infant is to undergo car bed monitoring prior to discharge.
DOCUMENTATION
Document the following on Car Seat Challenge Record:
a. Car seat brand
b. Time of last feeding
c. Oxygen
d. Baseline parameters previous to starting study and every 20 minutes up to 60
minutes. Document episodes of desaturations, bradycardia, apnea, and color
changes.
REFERENCES/ REGULATORY STANDARDS
 Altimier, L., Brown, B., Tedeschi, L. (2006). NANN guidelines for neonatal nursing
policies, procedures, competencies, and clinical pathways. NANN: Glenview.
 American Academy of Pediatrics. (1996) Safe transportation of premature and low
birth weight infants (RE 9617). Pediatrics, 97, 758–760.
 Fact Sheet 1999 Safe Ride News Publications (Seattle WA).
 Gomella, T. L., Cunningham, M. D., Eyal, F. G., & Zenk, K. E. (2004).
Neonatology: Management, procedures, on-call problems, diseases, and drugs. New
York: McGraw-Hill.
 USAA Educational Foundation. (2001). Are you using it right?
Origination Date
Approval Date
9/28/06
Review Dates
9/00, 1/03, 4/04, 8/05, 4/06, 4/07
CAR SEAT MONITORING
Committee Approvals:
Regional Neonatal Joint Practice: 9/00, 1/03, 4/04, 8/05, 4/06, 4/07
Pediatric Clinical Nurse Practice Committee: 9/02
Pediatric Joint Practice: 1/01, 9/02, 5/04
Pediatric Committee: 6/04
Policy & Procedures Committee: 9/05, 5/06, 5/07
MEC: 7/04, 7/06, 5/07
Operations Committee: 9/05, 6/06
Community Board: 10/05, 9/06
Regional Protocols & Procedures Committee: 2/01
Protocols & Procedures Committee: 2/03
Regional Central Standards Committee: 2/01
Central Standards: 2/03, 7/04
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CAR SEAT MONITORING
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