The so-called predischarge Car Seat Tolerance Screening is practised in some units, I think it is less common in European NICUs, at least, I have never come across in the Stockholm units where I have worked (during ~30y 🙂)

A recent systematic review an meta-analysis came suggested that the NICU stay was extended without clear benefits (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2844812)

Curious to know - what is your practise now and will your practise change?

Unfortunately, with the AAP statements is difficult to drop this practice of Car seat challenge. We want to stop doing it and replaced with common sense advice for car rides , but unable to find support to protect us from liability.

Agree, we need evidence to support not doing this before we can stop a test recommended by the AAP.

Hi Stefan,

Yes this is a predominantly a uniquely US issue which stems from a clinical practice guidelines that has been in place since the 90's, and was (at the time) based on two small cohort studies (~<50) that suggested preterm infants have more events in a car seat compared to term infants.

Practice is changing - in addition to the Kaiser centers in California, several other networks there have started to stop. There are likely pockets elsewhere.

Hopefully later in the year you'll see the second part of this project in print, which was a decision analytic model of the impact of car seat testing on NICU days and post-discharge outcomes. As you can imagine - the probability of benefit regarding post-discharge outcomes based on available evidence is small (David Braun's study, which they are also updating to double the sample size with Northern California). Conservative estimates of excess NICU days (ignoring other resource-related costs from additional testing) end up in the tens of millions of dollars annually (we have ~350,000 preterm infants discharged annually in the USA who would qualify for a car seat test, not including the term infants who also qualify at many places).

The AAP is holding practice change back, when in reality the CPG itself is based on no real evidence that the test prevents any adverse outcomes. Evidence should support doing a test in the first place, as opposed to proving ourselves we should stop.

Hi all and thanks for sharing your thoughts, interesting that this seems to be that regional (for North America). If this is related to the medicolegal context, are there any such cases?

@Brian King looking fw to part 2 :) !

And last thought, if many are doing this, and there is equipose, there should willingness to do some ethically approved study/trial?

Powering a trial would be difficult, and it depends on the outcome we are looking to prevent. The data we have is on "serious" events (death, readmission). That's are exceedingly rare, requiring a sample size in the tens of thousands.

A cluster-randomized design may be feasible. Perhaps something with stepwise deimplementation.

However - we also should ask ourselves whether it is a good investment of money to conduct a large trial to prove to us to stop something that we never proved to help in the first place.

While not doing any car seat tolerance screening in Sweden, we have had an issue with being able to refer a baby to home care, due to our car seats not being approved for infants less than 1500 g. This was an extremely small for gestational age infant, who was quite ”mature” in every other sense. And to use neonatal transport services was not an option, since the family needed to be able to come back for check ups, or if there was any other issue with the infant. So we do have great respect for car seats in Sweden aswell 😊

On 2/14/2026 at 6:21 AM, Stefan Johansson said:

The so-called predischarge Car Seat Tolerance Screening is practised in some units, I think it is less common in European NICUs, at least, I have never come across in the Stockholm units where I have worked (during ~30y 🙂)

A recent systematic review an meta-analysis came suggested that the NICU stay was extended without clear benefits (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2844812)

Curious to know - what is your practise now and will your practise change?

In the USA the AAP still recommends doing car seat tests for high-risk populations. severeal publications questioned the utilty of car seat testing as there is no strong evidence that it reduces hospital readmissions (Wade N. Harrison, Victor S. Ritter, Kori B. Flower, Carl J. Seashore, Skyler McLaurin-Jiang; The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization. Hosp Pediatr November 2022; 12 (11): 913–922. https://doi.org/10.1542/hpeds.2021-006509 ; Benjamin Hoffman, Mark Vining; Continued Challenges of the Car Seat Tolerance Screen. Hosp Pediatr November 2022; 12 (11): e393–e395. https://doi.org/10.1542/hpeds.2022-006929). Data from Kaiser Permanente showed that outcomes are no different regardless of car seat testing (Braun D, Kaempf JW, Ho NJ, Nguyen MH, Passi R, Burgos AE, Volodarskiy M, Villosis MFB, Gupta M, Habeshian TS, Tam HK, Litam KB, Hong QL, Dong CC, Getahun D. Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm. J Pediatr. 2023 Oct;261:113577. doi: 10.1016/j.jpeds.2023.113577. Epub 2023 Jun 22. PMID: 37353144.). Also, Canadian Pediatric Society has stopped doing routine car seat testing for lack of strong evidence supporting routine use (Narvey MR; Canadian Paediatric Society, Fetus and Newborn Committee. Assessment of cardiorespiratory stability using the infant car seat challenge before discharge in preterm infants (<37 weeks' gestational age). Paediatr Child Health. 2016 Apr;21(3):155-62. doi: 10.1093/pch/21.3.155. PMID: 27398056; PMCID: PMC4933079). As mentioned by other US colleagues, liability is significant in the USA. Unless the AAP updates its statement, it is hard for clinical neonatologists to stop doing this test. The UCSF Northern California Neonatal Consortium does not recommend routine ICSC testing before discharge for preterm infants or other infants thought to be "at risk" for abnormal oxygenation when in a car seat (Consensus Statement for Infant Car Seat Challenge (ICSC) Testing: UCSF Northern California Neonatal Consortium (NCNC) - UCSF Pediatrics). My personal bias is that passing this test depends significantly on appropriate positioning of the baby to prevent airway obstruction in neonates without congenital airway anomalies or neuromuscular disorders. The debate about car seat testing continues (Shah MD. Discontinuing Predischarge Car Seat Tolerance Tests: Is It Too Premature? J Pediatr. 2023 Nov;262:113663. doi: 10.1016/j.jpeds.2023.113663. Epub 2023 Aug 3. PMID: 37541426.).