Research at University of Maryland Golisano Children’s Hospital Finds One in Nine Newborns with Down Syndrome Does Not Pass Standard Car Seat Safety Screening Before Hospital Discharge

Approximately one in nine newborns with Down syndrome failed a routine car seat tolerance screening before hospital discharge in a first-of-its-kind study at the University of Maryland Golisano Children’s Hospital (UMGCH). The findings highlight the potential need for broader screening of infants at risk for breathing difficulties when placed in a semi-upright position. UMGCH is located within the University of Maryland Medical Center, the academic flagship hospital of the University of Maryland Medical System.

The study led by Natalie Davis, MD, a neonatologist at UMGCH, Professor of Pediatrics at the University of Maryland School of Medicine (UMSOM), and nationally recognized expert in infant car seat safety screening, is the only one to date focused exclusively on newborns with Trisomy 21 (Down syndrome). Previous studies have included infants with Down syndrome among broader patient populations, but no known study has specifically examined car seat screening outcomes in this group alone.

Important Findings for Discharging Infants with Down Syndrome

The new study analyzed 10 years of patient data from infants cared for at the University of Maryland Golisano Children’s Hospital. Researchers found that 11% of infants with Down syndrome who underwent car seat safety screening before hospital discharge failed the initial assessment. The most common reason was that their oxygen levels dropped while positioned in the semi-upright posture required in a standard rear-facing infant car seat.\

“Car seats save lives, but for some newborns with Down syndrome, the positioning required during travel may make it harder to maintain normal oxygen levels,” said Dr. Davis. “For years, researchers and clinicians have known that some infants experience breathing or heart rate changes when positioned in a car seat, but no one had specifically studied this question in newborns with Down syndrome. We found that more than one in 10 infants experienced cardiorespiratory events during testing, and notably, none of those infants were born prematurely.”

Infants with Down syndrome often have characteristics that can increase the risk of breathing difficulties, including low muscle tone, airway abnormalities, obstructive sleep apnea and congenital heart defects. Despite these known risk factors, relatively few hospitals specifically include a diagnosis of Down syndrome as a criterion for car seat tolerance screening.

Researchers reviewed the medical records of 84 infants with laboratory-confirmed Down syndrome born between 2013 and 2022. Seventy-five infants (89%) underwent car seat tolerance screening before hospital discharge, and screening results were available for 74 (99%) of those infants. Eight infants (11%) did not pass the initial screening. Seven failures were attributed to episodes of oxygen desaturation, while one had no documented reason for failure.

Current American Academy of Pediatrics guidance primarily recommends screening for preterm infants, meaning these newborns may not have been identified as needing evaluation if clinicians relied on prematurity alone.

The study also found that infants who failed the initial screening were nearly five times more likely to be readmitted within 30 days than those who passed (37.5% vs. 7.6%). For the infants in the first group, many of those readmissions were related to respiratory illnesses.

Importantly, the researchers emphasize that the findings do not suggest car seats are unsafe for infants with Down syndrome. Rather, they underscore the value of identifying infants who may benefit from additional monitoring, follow-up or intervention before leaving the hospital.

Advancing Safer Care for Newborns with Down Syndrome

“This study exemplifies the kind of research that translates directly into safer, more individualized care for newborns with special needs. It certainly confirms our own longstanding policy to perform the car seat safety test on these especially vulnerable babies, and we encourage expecting parents to speak with their own providers about screening for car seat issues at discharge,” said Dina El-Metwally, MD, PhD, Division Chief of Neonatology and Mary G. Cobey Endowed Professor of Pediatrics at UMSOM.  

She added, “By focusing on a population that has received little attention in previous research, Dr. Davis and her team have generated evidence that can help clinicians make more informed decisions as families prepare to take their babies home.”

The findings bring important evidence to an ongoing national discussion about car seat tolerance screening, a test routinely recommended for premature infants and frequently used for other newborns considered medically vulnerable. The authors conclude that larger, multi-center studies are needed to determine which clinical characteristics best predict screening failure and to help develop evidence-based screening protocols that maximize safety while making the most effective use of healthcare resources.

“Children with Down syndrome have unique healthcare needs that deserve dedicated scientific investigation,” said Steven J. Czinn, MD, Director of UMGCH, Chair of the Department of Pediatrics and the Drs. Rouben and Violet Jiji Endowed Professor at UMSOM. “This study fills an important gap in the medical literature and demonstrates how focused clinical research can generate practical insights that improve care for patients and families. As hospitals continue to evaluate how best to identify infants at risk for breathing and oxygenation challenges, studies like this help provide the evidence needed to guide safer, more personalized care. We are proud of Dr. Davis and her colleagues for leading this pioneering work."

An internationally recognized researcher in neonatal transportation safety, Dr. Davis has spent more than a decade studying factors that affect the safe transport of medically vulnerable infants. Her work, published in leading peer-reviewed journals including Pediatrics and Hospital Pediatrics, has documented significant variation in hospital car seat screening practices and helped drive efforts toward more evidence-based and standardized approaches to infant safety assessments.

About University of Maryland Golisano Children’s Hospital

Located within the University of Maryland Medical Center, the University of Maryland Golisano Children’s Hospital is a leading resource for children with critical and chronic illnesses throughout Maryland and the Mid-Atlantic. The hospital combines state-of-the-art medicine with family-centered care, offering more than 190 specialized pediatric physicians. Its services include Maryland’s largest Level IV neonatal intensive care unit and comprehensive programs in congenital heart conditions, asthma, epilepsy, and gastrointestinal disorders. Visit www.umms.org/childrens for more information.