Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Misc

Car Seat Angle Tolerance Screening (Pediatric) (8.38-P)

Car Seat Angle Tolerance Screening (Pediatric) (8.38-P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Misc



Effective Date:
May 31, 2017

 Administrative Manual
X Nursing Manual (Red)
 Other _______________

Policy #: 8.38P

☐ Original
☒ Revision

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Title: Car Seat Angle Tolerance Screening


To ensure that patients with specified risk factors undergo a car safety seat fitting and
angle tolerance screening by a trained provider prior to discharge, and are discharged
home in a car safety seat deemed safe for transport.


A. Patients who meet at least one of the following criteria will have an angle
tolerance screening (ATS) within 72 hours prior to discharge.
1. Premature infants less than 37 weeks gestational age at birth.
2. Infants with birth weights less than or equal to 2,500 grams.
3. Patients with history of apnea, bradycardia or oxygen desaturation
during current admission.
4. Any infant discharged on home oxygen therapy or apnea monitor.
5. Patients with physiologic immaturity, hypotonia, or cardio-respiratory
complications. Examples include: Down Syndrome, congenital
neuromuscular disorders, craniofacial anomalies, Obstructive Apnea,
Bronchopulmonary Dysplasia, Hypotonia, Micrognathia (Pierre Robin
sequence or infants with congenital heart defects).
6. Provider discretion.
B. If an ATS is required prior to discharge, the trained registered nurse (RN) or
Child Passenger Safety Technician (CPST) performing the ATS should assess the
patient’s car safety seat, its ability to provide proper fit and support, the need for
additional support rolls and provide education to the parent/guardian on proper
positioning and use of the car safety seat.


A. Cardio-respiratory monitor with pulse oximetry
B. Car safety seat or car bed in which patient will be discharged home
C. Crib or bassinet
D. Vehicle Seat


A. Inform parents/guardians about need for car safety seat evaluation and ATS.
1. The family will be instructed to bring the patient’s car safety seat to the
hospital prior to the evaluation. If an appropriate car safety seat is not

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available, the car seat and child passenger safety staff will assist the
family in obtaining an appropriate car safety seat.
2. The patient will be discharged in the same car safety seat used to
complete and pass the evaluation.
B. Assess Seat
1. Determine age of seat. Generally a seat should be less than six (6) years
of age. Consult car seat and passenger safety technician (CPST) for
questions related to seat condition and age.
2. Verify if seat is on a recall list by accessing the National Highway
Traffic Safety Administration (NHTSA) website: http://www-
a. If seat is on a recall list, inform parents and assess ability to obtain
new seat. If unable, work with family to obtain hospital issued seat
by placing a consult to a CPST.
C. Angle Tolerance Screening (ATS)
1. Evaluation Preparation
a. Perform within 72 hours prior to discharge.
b. Perform 30 minutes after feeding.
c. Patient will be placed on a cardio-respiratory monitor and pulse
oximetry for the entire testing period.
d. Car safety seat will be secured properly on a portable vehicle seat
for the ATS. The ATS for a neonate can be performed within a crib
or bassinet, if unable to obtain CPST help to secure base to
portable vehicle seat. A car safety seat should never be placed
directly on the floor, as this presents a safety risk for tripping/falls.
2. Positioning Patient into Car Safety Seat
a. Patient will be placed in the car safety seat following current
American Academy of Pediatrics (AAP) guidelines.
b. Patient should be positioned in car safety seat with buttocks flat
against the back of the seat.
c. Shoulder harness should be at or below patient’s shoulders and
snug so that no slack can be pinched at the shoulder.
d. Car safety seat’s retainer clip should be positioned at the midpoint
of the infant’s chest (just under axilla), not on the abdomen or in
front of the neck.
e. Car safety seat should be placed at the car safety seat’s
manufacturer’s recommended angle (usually at 45 degrees) for use
in the vehicle seat, check owner’s manual
f. Only head support padding and harness comfort covers that the car
safety seat manufacturer has included and crash tested with the car
safety seat can be used. No padding can be placed around the
patient’s head.
g. “Aftermarket” head supports that do not come with the car safety
seat are not regulated and may interfere with the performance of
the car safety seat reducing its ability to protect in a crash.
h. Padding must never be placed under or behind the infant
i. Many premature or small infants require additional positioning
support. Blanket rolls may be placed on both sides of the infant to
provide lateral support for the head and trunk,

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3. Monitor and Observe
a. Patient should remain undisturbed for 90 minutes or the duration of
travel home, not to exceed (3) hours.. If ATS is to be performed
longer than 90 minutes, due to duration of travel home, the patient
should be taken out of seat for feeding and cares after 90 minutes,
and returned to the seat for the remainder of the testing period.
4. Screen result: PASS
a. An ATS result of “PASS” defined as the patient remaining
undisturbed for at least 90 minutes or the duration of travel home
without having an apnea, bradycardia, or desaturation event,
defined as follows, unless alternative parameters given by the
i. Apnea: greater than 20 second cessation of respirations
ii. Bradycardia: less than 80 beats per minute for greater than
10 seconds.
iii. Oxygen desaturation: SaO2 less than 90% for greater than
20 seconds
5. Screen result: FAIL
a. A patient would “FAIL” the ATS if any of the following occurs,
unless different parameters outlined by provider are acceptable:
(i.e., patient saturations should not fall below 85%):
i. Apnea: greater than 20 second cessation of respirations
ii. Bradycardia: less than 80 beats per minute for greater than
10 seconds.
iii. Oxygen desaturation: SaO2 less than 90% for greater than
20 seconds.
b. In the event of apnea, bradycardia and/or oxygen desaturation,
stimulation, repositioning and other appropriate interventions will
be performed and documented. A provider should be notified of
the event and interventions.
i. A provider may request a re-test in the car safety seat 24 –
48 hours after medical evaluation and intervention., The
provider will determine a medically safe plan for
transportation prior to discharge.
6. Car bed discharge criteria
a. The ATS needs to be repeated with the infant in the car bed,
following the same criteria as outlined above (some pre-term or
physiologically unstable infants may demonstrate similar rates of
apnea, bradycardia, and desaturation in the car bed; in this case,
further evaluation of discharge readiness must be performed by the
b. Parents whose infant is discharged with a car bed should be
counseled to avoid use of other upright equipment including infant
swings, infant seats, backpacks, slings, and infant carriers.
c. Transitioning from car bed to semi-reclined car seat:
i. Repeat ATS is recommended prior to transitioning from car
bed (performed by primary care provider at his/her

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D. Car Seat Education
1. Provide and document car seat education in clinical record as part of
patient’s discharge planning. This education should include:
a. Proper positioning, harness adjustments and securing of the
patient in car safety seat.
b. The back seat is the safest place for the car safety seat. Never place
a car safety seat in front of an airbag.
c. Use a rear-facing car seat until infant is at least 24 months of age.
d. Patients discharged with a home monitor should use this
monitoring equipment during travel. Parents / caregivers should be
instructed to secure monitoring equipment (i.e., wedge on the floor
or under vehicle seat). This will prevent equipment from becoming
a dangerous projectile in the event of a crash or sudden stop.
2. Parents/caregivers must independently demonstrate proper car safety
seat use and safe positioning of patient in seat prior to discharge.
3. Advise families that travel should be minimized. Any travel time beyond
90 minutes should include a rest stop to remove the patient from the car
safety seat for a brief period prior to resuming travel in their car safety
4. The car safety seat should only be used for travel and never for use in
the home. Patients should never be left unattended in a car safety seat.
E. Car Safety Seat Inspection
1. Parents/caregivers should be encouraged to schedule a car safety seat
inspection and vehicle fitting prior to their child’s ATS and discharge.
2. Parents/caregivers should be advised to read their car safety seat
manufacturer’s instructions and their vehicle manual in addition to
practicing installation of their car safety seat.
a. NICU patients can be scheduled for car safety seat inspection at
the car safety seat clinic at American Family Children’s Hospital.
b. Additional car safety seat inspections can be made by scheduling
an appointment through Safe Kids Madison:
i. To schedule call (608) 890-8999 or send an e-mail to
F. Discharging the patient in a car safety seat
1. Parent/caregiver should be the last one to position and secure infant in
the car safety seat.
2. Parent/caregiver is responsible for installing their own car safety seat in
their vehicle.

A. Child Passenger Safety Core Team:
B. National Highway Traffic Safety Administration (NHTSA) website: http://www-

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A. American Academy of Pediatrics (AAP). Car Seats: Information for Families for
2014. http://www.healthychildren.org/English/safety-prevention/on-the-
B. American Academy of Pediatrics, National Highway Transportation Safety
Administration (NHTSA), Children’s Hospital Association and the National
Safety Council. Hospital discharge recommendations for safe transportation of
children. March 2014. Available at: http://cpsboard.org/cps/wp-
C. American Academy of Pediatrics (AAP) (2009). Safe transportation of preterm
and low birth weight infants at hospital discharge. Pediatrics, 123(5), 1424-1429.
D. Davis NL. Car seat screening for low birth weight term neonates. Pediatrics.
E. Davis, N. L., Zenchenko, Y., Lever, A., & Rhein, L. (2013). Car seat safety for
preterm neonates: implementation and testing parameters of the infant car seat
challenge. Academic Pediatrics, 13(3), 272-277.
F. DeGrazia, M., Guo, C. Y., Wilkinson, A. A., & Rhein, L. (2010). Weight and age
as predictors for passing the infant car seat challenge. Pediatrics, 125(3), 526-531.
G. National Highway Traffic Safety Administration (NHTSA) website: http://www-
H. Salhab, W. A., Khattak, A., Tyson, J. E., Crandell, S., Sumner, J., Goodman, B.,
& et al. (2007). Car seat or car bed for the very low birth weight infants at
discharge home. The Journal of Pediatrics, 150(3), 224-228.


American Family Children’s Hospital (AFCH) Child Safety Technician
Clinical Nurse Specialist, Neonatal Intensive Care Unit (NICU)
Medical Director, Neonatal Intensive Care Unit (NICU)
Nursing Patient Care Policy and Procedure Committee, May 2017


Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive