Routine car seat screening shows no clear benefit for infants

Predischarge car seat tolerance screening (CSTS) does not reduce postdischarge readmission or mortality for preterm and at-risk full-term-born infants, according to a recent study published in JAMA Network Open.¹

CSTS is defined as a newborn being positioned in a car seat to undergo observation and cardiorespiratory monitoring for a fixed period of time. This method was endorsed by the American Academy of Pediatrics in 1991 as a way to identify infants at risk of adverse outcomes based on vital sign instability.²

“While studies have continued to investigate variations in CSTS eligibility and failure criteria, few have focused on whether routine CSTS prevents harm or improves patient outcomes,” wrote investigators.¹

Study design and eligibility criteria

The systematic review and meta-analysis was conducted to evaluate the link between CSTS with length of stay and postdischarge outcomes. Articles published before June 2025 with a newborn population before discharge and CSTS with established failure criteria were eligible for inclusion.

Study subgroups included randomized clinical trials, nonrandomized intervention studies, and single-group observational studies. Observational studies that did not report CSTS failure, observational studies of adherence to testing recommendations, surveys of clinical practice, and studies limited to subgroups beyond gestational age and birth weight were excluded.

Articles were identified through searches of the PubMed, Embase, and Web of Science databases. Title, abstract, and full-text screening were performed by 2 authors. Extracted data included the study design, number of infants, gestational age, birth weight, CSTS eligibility, and failure criteria.

In-hospital outcomes were also extracted when available. These included rates of first and subsequent test failure, timing of repeat test, and length of stay. Postdischarge outcomes included hospital readmission, death, and neurodevelopmental impairment.

CSTS failure rates across settings and populations

There were 21 studies included in the final analysis, most of which had a single group and no comparison groups of infants without CSTS. However, a comparison group was reported in 3 of the studies. Most infants were born preterm, with 67% of studies including patients admitted to the neonatal intensive care unit (NICU) or well-baby nurseries.

On overall rate of 8.62 CSTS failures per 100 patients was reported across studies. Additional rates of CSTS failure included:

• 9.86 per 100 patients for testing in the nursey
• 7.11 per 100 patients for NICU patients
• 8.56 per 100 patients for preterm infants
• 10.72 per 100 patients for full-term infants

An increased failure rate in the nursery was also report in studies where patients received their first testing in the nursery or NICU. Six studies compared preterm and full-term infants, with increased failure rates reported in term infants.

In studies with available data about repeat CSTS, repeat testing occurred 12 to 48 hours after the initial test. The overall rate of repeat failures was 24.40 per 100 patients.

Length of stay and postdischarge outcomes

There were 2 studies comparing the predischarge length of stay in patients with vs without CSTS. In these studies, no significant differences were observed, except for a longer length of stay by 35.5 hours linked to routine CSTS use in one study’s stratified analysis.

One study found a decrease in postdischarge mortality after stopping CSTS, but this difference was not significant when adjusting for other clinical factors, with an adjusted odds ratio (OR) of 0.94. Readmission rates within 30 days of discharge also did not significantly differ based on CSTS reception, with an OR of 1.05.

Overall, no links to 30-day mortality or hospital readmission were reported for CSTS, with approximately 9% of infants failing initial testing. However, the evidence had very low certainty.

“These failure events potentially contribute to prolonged hospitalization in this subset of infants without clear evidence of benefit,” wrote investigators. “As such, current recommendations for routine CSTS in all preterm infants may merit reevaluation.”

References

1. King BC, Dalvie N, Hay S, Jensen EA, Zupancic JAF. Predischarge car seat tolerance screening in preterm and at-risk full-term Infants: a systematic review and meta-analysis. JAMA Netw Open. 2026;9(2):e2558197. doi:10.1001/jamanetworkopen.2025.58197
2. Committee on Injury and Poison Prevention and Committee on Fetus and Newborn. American Academy of Pediatrics Committee on Injury and Poison Prevention and Committee on Fetus and Newborn: safe transportation of premature infants.Pediatrics. 1991;87(1):120-122. doi:10.1542/peds.87.1.120