The article by Magnarelli et al1  in this issue of Pediatrics highlights 3 major issues of importance to clinicians and families caring for infants born late preterm. One is the importance of determining cardiorespiratory stability, especially before being tested for car seat tolerance in preparation for discharge; the second is the importance of appropriate use of car safety seats at the time of hospital discharge; and the third is the value of having a hospital discharge policy in place.

The continuing discussion regarding the value of car seat tolerance screening (CSTS) is further informed by this review because it strengthens the need for CSTS. A significant percentage (4.6%) of infants born late preterm have not achieved the same level of cardiorespiratory stability when positioned in a car safety seat as when in an open crib and have not been deemed to have met the criteria for hospital discharge as defined by the American Academy of Pediatrics.2  In this study, there is variability in frequency of CSTS failure depending on location (newborn nursery versus NICU), but the differences by location alone are not important because significant numbers of infants born late preterm are affected regardless of where their care is provided.

The study does not differentiate outcomes of infants with and without congenital anomalies. Descriptions of the comorbidities relative to outcomes would have been helpful, but infants with hypotonia and other neuromuscular problems and those with repaired congenital heart disease are well recognized to have increased risk of CSTS failure.3 

An important point emphasized by the authors of this study is that, at least in the late preterm population, the CSTS serves to reveal unrecognized clinical findings and can ensure that the infant is discharged at the desired level of cardiorespiratory stability and with appropriate medical support.

The discussion emphasizes many important points, including the need for parental education regarding proper positioning of infants in car seats and use of car seats only for travel. Studies reveal that deaths in seating devices have occurred 60% of the time in car safety seats4  and reveal the importance of removal of infants from the car seat when out of the car.

This article also illustrates the value of hospitals having discharge policies and appropriately trained staff. The recommendations for a hospital discharge policy are provided in the joint hospital discharge recommendations of the American Academy of Pediatrics, the National Highway Traffic Safety Administration, the Children’s Hospital Association, and the National Safety Council.5  Use of the hospital policy will expedite having the child’s own car safety seat available for the screen, implementation of the CSTS, and providing instruction for caregivers before discharge. Although the Magnarelli et al1  study does demonstrate that the test itself does not necessarily contribute to the infant’s length of stay, care for late preterm infants and their potential outcomes after discharge are optimized by having a hospital discharge policy in place that is used consistently.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1703.

     
  • CSTS

    car seat tolerance screening

1
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2020
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2
Engle
WA
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“Late-Preterm” infants: a population at risk [published correction appears in Pediatrics. 2008;121(2):451]
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3
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2008
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145
4
Liaw
P
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RY
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Infant deaths in sitting devices
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Pediatrics
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2019
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144
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1
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5
National Highway Traffic Safety Administration
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Hospital discharge recommendations for safe transportation of children: best practice recommendations developed by an expert working group convened by the National Highway Traffic Safety Administration. 2015. Available at: www.nhtsa.gov/sites/nhtsa.dot.gov/files/documents/812106_hospitaldischrgerecsafetranschildren.pdf. Accessed October 5, 2019

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.