Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge

Safe transportation of preterm and low birth weight infants requires special considerations. Both physiologic immaturity and low birth weight must be taken into account to properly position such infants. This clinical report provides guidelines for pediatricians and other caregivers who counsel parents of preterm and low birth weight infants about car safety seats. Pediatrics 2009;123:1424–1429 INTRODUCTION Improved survival rates and earlier discharge of preterm ( 37 weeks’ gestation at birth) and low birth weight ( 2500 g at birth) infants have increased the number of small infants who are being transported in private vehicles. Car safety seats that are used correctly are 71% effective in preventing fatalities attributable to passenger car crashes in infants.1 To ensure that preterm and low birth weight infants are transported safely, the proper selection and use of car safety seats or car beds are necessary. Federal Motor Vehicle Safety Standard (FMVSS) 213, which establishes design and dynamic performance requirements for child-restraint systems, applies to children weighing up to 65 lb. However, the standard has no minimum weight limit and does not address the relative hypotonia and risk of airway obstruction in preterm or low birth weight infants. Most rear-facing car safety seats are designated by the manufacturer for use by infants weighing more than 4 or 5 lb, with some designated for use from birth regardless of weight. Infant dummies as small as 3.3 lb have been shown to be satisfactorily restrained in standard rear-facing car safety seats during crash tests.2,3 Test dummies, however, cannot replicate the airway and tone variables that occur in preterm infants, and there is no information on restraint of infants who weigh less than 3.3 lb (1.5 kg). Rear-facing car safety seats provide the best protection in a frontal crash, because the forces are transferred from the back of the restraint to the infant’s back, the strongest part of an infant’s body. The restraint also supports the infant’s head. Severe tensile forces on the neck in flexion are also prevented by use of rear-facing car safety seats.4 The long-term experience and documented protective value of car safety seats make them the preferred choice for travel for all infants who can maintain cardiorespiratory stability in the semireclined position.4 A car bed that meets FMVSS 213 may be indicated for infants who manifest apnea, bradycardia, or low oxygen saturation when positioned semireclined in a car safety seat.2,5 Of note, some preterm and term infants positioned in car beds and car safety seats seem to have similar rates of apnea, bradycardia, and oxygen desaturation.6,7 A car bed is designed to accommodate an infant in a fully reclined position and is oriented in the vehicle seat perpendicular to the direction of travel. An infant is secured in the car bed with an internal harness, and the car bed is secured to the vehicle with the vehicle’s seat belt. Car beds, like car safety seats, have specific weight requirements designated by the manufacturer and, like car safety seats, should be used according to manufacturer recommendations. The size of the infant, especially for those born preterm, is an important consideration when selecting a car safety seat or car bed.2,8 Weight, length, neurologic maturation, and associated medical conditions (especially bronchopulmonary dysplasia) all influence the potential risk of respiratory compromise for infants in seating devices.6,9 Preterm infants are subject to an increased risk of oxygen desaturation, apnea, and/or bradycardia,10 especially when placed in a semireclined position in car safety seats.5,11–13 Furthermore, frequent cardiorespiratory events and www.pediatrics.org/cgi/doi/10.1542/ peds.2009-0559 doi:10.1542/peds.2009-0559 All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict-of-interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.