One of the most difficult and harrowing experiences of my life was sitting by my premature baby’s crib and waiting. And then waiting some more. It seemed like all I ever did was wait, a million tiny steps forward and back, all culminating in the words, “Let’s talk about a discharge date.”

Those last days felt fraught, as I worried that a setback would delay me finally, finally taking my baby home.

One of the last steps for most preemies is the “car seat test.” Premature babies aren’t just small infants, they need special precautions to assure they will be able to handle life outside of the hospital walls. So in addition to the day-to-day ability to eat and keep a normal heart rate and oxygen level, they need to be able to do those last two while in the car.

Soon before discharge you will be asked to bring in your infant’s car seat, where the nurses will check to make sure it’s an appropriate seat, and will strap the baby in for a period of time (frequently 90 minutes) to make sure all the vital signs stay within the normal range. The exact practices will vary from hospital to hospital, and baby to baby, but this is how it usually goes.

Make sure you have a seat that will fit a preemie.

Specifically, look for one that is rated down to four pounds. Even if your baby is heavier than this, it’s more likely to fit well. You want to make sure the lowest strap slot is low enough to be at or behind his shoulders. Read the manual! Then read it again.

You may have to watch your baby cry.

They will try to time it for one of your baby’s sleepiest times, but much like in the car, sometimes she will wake up and scream. You will be able to talk to her, and maybe offer a pacifier, but if you remove her from the seat the time period will start over. It’s hard to feel powerless as you watch your tiny child scream.

She passed! Hurray! Now what?

Preemie airways are even smaller than that of other newborns, so be extra careful that your seat is at the appropriate angle in the car. Get the straps snug. This may mean taking off any strap covers (check the manual first!), because your baby won’t take up much room in that seat. You can use a rolled up washcloth between your child and the crotch strap, and on either side of her head.

Do not use any aftermarket car seat accessories! This is true for all seats and all children, but it’s especially important for your fragile little guy or gal. No infant inserts, strap covers, head positioners, etc. If it did not come with the seat, or was not sold by the manufacturer to go with the seat, do not use it.

Preemies are especially at risk for positional asphyxia. Once you’re out of the car, take the baby out of the seat. Infant seats are meant for the car and the stroller, and can put tiny babies in danger of cutting off their airway when not used at the correctly reclined angle. If you have a very long drive home (which is not unusual for NICU parents), the nurses will likely suggest you stop every hour or so to check on your baby, and make sure she is still positioned well. If possible have another adult sit in the back seat.

Congratulations! You’ll be amazed at how quickly she grows to fill that seat.

**If there is a conflict between the advice seen here and your car seat manual, always defer to the manual.**