Infant Death In 1995, parents of a newborn baby girl were shown a 1989 car seat instructional video before discharge from a maternity hospital. The video recommended transporting the infant in a restraint in the front seat so the driver could monitor the infant. This was routine advice only a few years ago. No mention was made of the hazard of a passenger frontal air bag to an infant, because that had not been an issue when the video was made.

Within a month of birth, the infant died from injuries due to the impact of the air bag during a crash in the parents' new car. Her mother survived with minor injuries. The hospital was sued and has been severely criticized for using a video that failed to warn about this new hazard. The parents did not notice the warning flyer they received in their hospital packet!

Child Safety Early last year, during a routine child safety seat check by law enforcement officers, two expectant parents were shown how to correctly install a child safety seat for their expected child. The officers explained the importance of installing it in the rear seat of the vehicle.

Six months later, the "new" parents and their baby were involved in a traffic crash. The child was found safe and secure in a correctly installed child safety seat. The parents had followed the directions of the police officers and had remembered the important public service message of putting children in the rear seat.

Child Passenger Safety Materials
Review and Evaluation Tool

New issues regarding child safety seats are critical to understand. Today, these issues center around air bag safety, selection of products for children who are very small or large for their age, and incompatibility of safety seats with vehicle design. Every day parents read and view consumer material that depicts unsafe practices and lacks current information. If you are distributing brochures, videos, or other literature that does not address today's safety issues accurately, you could be placing your agency, your members, or your clients at great risk.

How to use this Guide.

To be certain the materials your office, agency, or institution uses and distributes are accurately promoting the safest use of child restraints, you need to:

• Review existing materials annually. Use this guide today and updated criteria in future years.
• Throw out those containing information that could be hazardous
• Replace materials that are no longer accurate and up-to-date
• Evaluate products carefully before purchase or during development of new materials
• Use peer review when creating new materials
• Complete and return the Inventory Worksheet in the back of this guide to help us reduce injuries and fatalities due to inaccurate information.

Why is periodic evaluation of child passenger safety materials so critical?

• Automobile and child safety seat designs are changing constantly.
• Proper use is a matter of life and death.
• Inaccurate materials could result in personal, organizational, or institutional liability.

What are today's critical issues?

In 1997, it is especially important to know that:

• Air bags are hazardous to infants and children age 12 and under.
• Infants should ride facing the rear until they are at least one year of age and weigh at least 20 pounds.
• All children are safer in the rear seat in any vehicle.
• Secure anchorage of a safety seat in a vehicle is essential, but may be very difficult.
• The vehicle owner's manual is a source of vehicle-specific information on anchorage of child restraints. However, in some aspects of child passenger safety a manual may not be up-to-date or may be unclear.
• Access to educational materials with an easy reading level and multiple languages is essential to give parents in our diverse population the information they need.

The guide is divided into two parts.

Part One: Critical Issues

A brief checklist for finding the major problems with existing materials, particularly flyers and pamphlets that offer limited but critical information. Comprehensive material, such as videos and training manuals, should also pass this easy checklist.

Part Two: Comprehensive Guidelines

This checklist should be used to evaluate sources claiming to provide comprehensive information, such as instruction booklets, videos, and training materials. This section should also be consulted by individuals who are writing and producing any materials related to the proper use of child restraints.

This guide follows current "best practices" as defined by research and organizations such as the American Academy of Pediatrics. Not all products comply with "best practices". The checklists in this guide offer criteria to use as of September 1997.

1. OUTDATED INFORMATION

If your materials advise or depict any of the following, destroy the supply and replace it immediately.

	Putting an infant in a rear-facing restraint in the front seat, with or without a passenger frontal air bag. BECAUSE: Rear-facing infant in front seat can be killed by the passenger air bag.
	Children ages 12 and under riding in front seat, with or without a passenger frontal air bag. BECAUSE: Forward-facing children (ages 12 and under) risk serious injury from passenger frontal air bags, especially if they are not wearing lap/shoulder belts correctly or sitting too close to the dashboard.
	Facing infant forward at 20 lbs. or when infant can sit up, without regard to age. BECAUSE: Best practice -- Encourage transporting infants rear-facing in the back seat as long as possible (to at least age one) to protect from neck and spinal injury. American Academy of Pediatrics now recommends that infants ride rear-facing to at least age one and at least 20 lbs. A growing number of new products can be used this way.
	Moving child directly to a safety belt from a convertible safety seat. BECAUSE: Most children up to age 6-8 need booster seats to achieve correct fit with vehicle lap/shoulder belts. Lap only belts can cause seat belt syndrome (spinal and abdominal injury) due to poorly fitting safety belts; belt lying across abdomen instead of thighs. Some booster seats are appropriate up to about 80 lbs. but few children use them.

2. IMPORTANT NEW UP-TO-DATE INFORMATION

If your materials fail to mention any of the following, replace them as soon as possible. In the interim, add educational materials from the National Highway Traffic Safety Administration and the Air Bag Safety Campaign.

	The hazard of a passenger frontal air bag to rear-facing infants in the front seat. BECAUSE: Air bags can cause death or serious brain injury by striking the back of the child restraint.
	The potential hazard of a passenger frontal air bag to a child age 12 and under facing forward in the front seat. BECAUSE: Air bags can cause death or serious head and neck injuries, especially when a child is riding unrestrained or incorrectly restrained.
	Keeping the infant facing the rear up to at least one year of age and at least 20 lbs. BECAUSE: Rear-facing position cradles the baby's large, heavy head and protects weak neck and back from spinal injury.
	Using a booster seat rather than a safety belt, for a child who has outgrown a convertible or toddler model, but who is not big enough to fit adult safety belts. BECAUSE: Booster seats position the lap or lap/shoulder belts to fit the small child properly, reducing the risk of belt-related injury. Boosters recommended up to 80 lbs.
	The need to install the safety seat securely. BECAUSE: Incompatibilities between safety seats and vehicles are common and pose a potential risk of injury. Secure installation is essential.
	The benefit to all children of riding in the rear seat. BECAUSE: The rate of injury is lower for rear seat passengers than for front seat occupants, regardless of the presence of a passenger frontal air bag.

3. READABILITY REVIEW

If your materials are limited in the following ways, add multi-lingual materials and information written at a fifth-grade level.

	Reading level above grade 8. BECAUSE: Average reading level for US population is grade 8.
	Availability in English only in areas with diverse populations. BECAUSE: All family members, including grandparents, need to receive information on child passenger safety in a form they can understand. Consider materials with clear photos or drawings and minimal text when translations from English are not available.

Critical Issues Checklist

Please duplicate this form and use it to evaluate any materials you are using or plan to use which includes BASIC information on child passenger safety.

DESTROY AND REPLACE
your materials if they advise or depict:

	Putting an infant in a rear-facing restraint in the front seat, with or without a passenger frontal air bag.
	Children ages 12 and under riding in front seat, with or without a passenger frontal air bag.
	Facing infant forward at 20 lbs. or when infant can sit up, without regard to age.
	Moving child directly to a safety belt from a convertible safety seat.

PROVIDE ADDITIONAL MATERIALS
if they fail to mention:

	The hazard of a passenger frontal air bag to rear-facing infants in the front seat.
	The potential hazard of a passenger frontal air bag to a child age 12 and under facing forward in the front seat.
	Keeping the infant facing the rear up to at least one year of age and at least 20 lbs.
	Using a booster seat rather than a safety belt, for a child who has outgrown a convertible or toddler model, but who is not big enough to fit adult safety belts.
	The need to install the safety seat securely.
	The benefit to all children of riding in the rear seat.

ADD MATERIALS AND INFORMATION
if your materials are limited to:

	Reading level above grade 8.
	Availability in English only in areas with diverse populations.

Instruction booklets, videos, slide shows, handbooks, and training materials should include all the instruction and information below. Even materials that present limited information, such as pamphlets and flyers, should be consistent with this checklist. Check the items that are included in the materials you are reviewing.

1. AIR BAG SAFETY

If existing materials have no warning about air bags, immediately add supplemental materials with air bag information and replace old materials as soon as possible.

	How to know if a vehicle has a passenger frontal air bag The letters "SRS," "IRS," "SIR" or the words "air bag" may be embossed on dash, or there will be a warning sticker on visor; consult owner's manual. In some vehicles, there may be no obvious indicator on the dashboard (clues might include no glove box or one that is mounted very low on dash).
	How an air bag can kill Deploys with high energy, hitting objects close to dash such as the back of rear-facing seat or the older improperly or unrestrained child, age 12 and under, who slides forward during pre-impact braking. (The air bag does NOT smother child). Incorrect belt use by children: permitting the child to place the shoulder belt behind the back, or to perch on the edge of the seat while wearing lap and shoulder belts.
	Air bag turn-off switches Owner's manuals should be checked for information about special occupant protection devices built into a vehicle. Some vehicles with no back seat have shut-off switch to turn off passenger air bag while an infant or child is in place. A few new vehicles have special sensors for use with specific child restraints.

2. SEATING POSITION

Even if no air bag is in the vehicle, the rear seat is usually the safest position for infants and children.

	Rear-facing in rear seat A normal, healthy newborn placed in a correctly used and positioned child safety seat is not at risk if unobserved in rear seat; stop to check on longer trips. If infant has a medical condition and must be observed, have another adult sit with baby in rear seat or limit trips.
	Child over age one in front seat with air bag If there is no way to avoid carrying a child over age one in the front seat with a passenger frontal air bag, make sure he/she uses an appropriate restraint system correctly. Push the vehicle seat all the way back.
	The center front-seat position (lap belt only) Use only as a last resort. Make sure child is correctly secured and vehicle seat is moved as far back as possbile.

3. CHILD RESTRAINT SELECTION

The "best" car seat fits the child, fits in the vehicle with its belt, and is convenient to use on every ride. Newer products are generally easier to use correctly.

	No one model is "best" Some restraints are easier to use than others; some will not fit into certain vehicles; some of each type are less well suited for the child's size and development (such as a child very small or very large for his or her age and development).
	Types of car seats Read label for recommended weights for specific products. Rear-facing (Infant only): birth to 20-22 lbs., small, convenient to carry to car. Use rear-facing only. Move to larger seat before the head reaches the top of the shell. Some newer products have 22 lb. limit. Some products also have a convenient base that stays in the vehicle. Convertible: birth to 40 lbs. Choose one with 5-point harness if used from birth. Use reclined for rear-facing and upright for forward-facing position. Some newer products allow infant to ride rear-facing above 20-22 lbs. Move to high-backed child seat or booster when child's ears are above the seat, or shoulders above the top harness slots. Forward-facing only: weight limits vary. Check instructions; some have harness for child under 40 lbs. and are used as belt-positioning boosters for heavier child. Some are integrated into the vehicle seat. Booster: for children over 30-40 pounds who have outgrown convertible/toddler seats. Use up to 60-80 pounds, until the vehicle lap/shoulder belts fit correctly and the child fits well in the vehicle seat, with knees bending easily over the edge of the seat and child's back flat against vehicle seat back. A belt-positioning booster is preferred. This type is made specifically to improve fit of lap/shoulder belts; some can be used up to 80 lbs. Special restraints include: car bed for infants with breathing problems; harness and seat for children in casts; harness and positioning seats for support.
	For the most flexibility and best potential fit, choose an infant-only restraint first; if baby grows to above average weight then select a convertible restraint with a rear-facing weight limit of 22 lbs. or more.

4. ADJUSTING CHILD RESTRAINTS

Correct adjustment of harness straps and recline angle are very important for the safe and proper use of restraints.

	Newborn infants must ride reclined at 45 degrees to keep baby's head from dropping forward. Check that base of restraint is horizontal; if necessary, place rolled towels under the base to compensate for seat slope. Do not recline at lower than 45 degrees; baby could slide out head-first in a crash.
	Forward-facing children should ride in upright position. This allows the harness system to restrain the body most effectively and is preferred to semi-reclined position available in some convertibles. Most vehicle seats slope, tilting an upright restraint back at a comfortable angle.
	Harness slot positions: Rear-facing position uses lowest slots (to hold baby's head as low as possible in the restraint in a crash). Straps should be at or below infant's shoulders. Forward-facing position uses top slots (unless CRS instructions specifically state otherwise) at or above child's shoulders. This minimizes slack and forward movement. When harness straps are moved or replaced after cleaning, be sure they are correctly placed and the harness adjuster is secured. Some straps must be double-backed through the metal adjuster to stay tight in a crash.
	Adjust harness for a snug fit. Check harness adjustment frequently. Change length as child grows. Adjust snugly for thinner/thicker outer clothes. Adjust to fit child snugly without being too tight (should be able to slip only one finger under harness at chest).
	Retainer clip holds straps on shoulders. Place at armpit height. If too high, can interfere with airway; if too low, could allow shoulders to slip out of restraint. (Not all models have retainer clip.)

5. VEHICLE FIT AND CHILD SEAT INSTALLATION

Not all restraints fit securely in all vehicles. Consumers are advised to try a selected model before purchase to be sure it fits properly in all family vehicles. Fasten belt tightly and make sure seat cannot move more than about one inch forward or sideward. It is okay for the top of a rear-facing seat to tip up toward the back of the vehicle.

	Rear seat fit Available space in rear seat may be too short. Make sure the child restraint can be installed correctly in the rear seat of vehicles it will be used in. Check for secure fit in vehicle seat and tight attachment with vehicle belts. The rear seat space may be too short (front-to-back) for a rear-facing convertible, however it is okay for top of the restraint to rest against the back of the front seat. Rear seat may not be wide enough for three restraints side-by-side. In some cases, using a restraint with a narrower base may help. Headroom may be too low for some convertibles with swing-up shields.
	Restraint may have more than one belt path. Use the path specified for the way the restraint is being installed (forward- or rear-facing; with or without base, etc.).
	How to keep belts tight around child restraint: Switchable retractor (pull belt webbing all the way out, then make sure it locks as it retracts). Locking or cinching latchplates on lap only or lap/shoulder belts (lap portion of belt stays tight after being adjusted). Regular locking clip and belt-shortening (heavy-duty) clips; warning against use of regular locking clip to shorten a belt. Some new child seats have a built-in locking feature.
	Do not secure a child restraint with an automatic shoulder belt or lap/shoulder belt attached to door. Special "attaching belt" for child restraints available to modify automatic front lap/shoulder belt systems attached to the door for securing a child restraint (see owner's manual). The rear seat is safer, avoids these problems.
	Forward-anchored belts can make secure installation difficult if they are more than 2" forward of junction between upper and lower cushions (called "seat crack" or "bight"). Child seat buckle available to adapt some front seat belts. Tether will help anchor restraint more securely.
	Use of tether to help anchor forward-facing child restraint more securely, especially if belts are forward of seat crack. Use only manufacturer-supplied tethers. Tethers are now available for many forward-facing car seat models. Other models will become available soon. Many vehicles have predrilled holes for tether anchors.
	Seat cushion contours: child restraint with narrow base may fit into bucket seats; broad, arched base may fit on hump in center rear.
	Options for better installation: Use of thin, rubberized pad may reduce slippage on smooth seats. Some restraints have more than one belt path for rear- or forward-facing position. This gives alternatives to try for secure installation. Infant-only restraints with removable bases can be tried with and without the base to find best fit on seat and with belts.

6. SAFETY BELT FIT FOR LARGER CHILDREN

Children should use safety belts after they have outgrown booster seats and when safety belts fit correctly. Proper safety belt fit is critical.

Correct safety belt fit: Teach child to sit with buttocks against the seat back and to avoid leaning forward. Lap belt lies across the top of thighs, not over abdomen. Slouching contributes to poor belt fit, which can be hazardous. If the child's legs are so short that the knees cannot bend naturally at the edge of the seat, the child is likely to slump and the lap belt will ride up. Use of a booster seat will allow child to sit without slouching. Correct belt fit depends on the child's height when seated. The shoulder belt should rest across the shoulder (collar bone) and across the center of the chest. Putting the shoulder belt behind the back or under the arm can produce very serious injuries in a crash. If no shoulder belts are in the rear seat, they can be retrofitted, or an alternative product (E-Z-On Vest or Y harness) can be installed.

7. REFERRAL FOR PROBLEMS

Consumers should be advised to follow directions in both the child restraint instruction booklet and the vehicle owner's manual.

	Call manufacturer if an instruction booklet or vehicle owner's manual is not available. Note: there may be little information on child restraint use with belts in older vehicle manuals. Vehicle manuals should not be used as the primary source of information on child restraints themselves.
	Refer users to state highway safety office or child passenger safety program, NHTSA hotline, and/or the manufacturer/distributor. A person may need to make several calls to get complete answers.

8. ADDITIONAL CONSIDERATIONS

	Double-check all visuals. It is remarkably easy to make inadvertent errors in diagrams, drawings, cartoons, photos, and videos. People remember what they SEE!
	Minimize visuals showing incorrect use or behavior because people often imitate what they see, rather than read the text. If incorrect images are included intentionally, mark each graphic, photo, or video shot with a large "X" or the universal "no" symbol so the viewer will recognize that the depiction is incorrect. Commenting on incorrectness of a visual image only in the text or narration is not sufficient.
	Make sure your audience can understand. Half of the US population reads below the 8th grade level! Medicaid requires 4-5th grade level for health education materials in some states. Observe cultural sensitivity in language and illustration.
	Date and source are extremely importantInclude a date on all materials you develop or modify to help you or others in evaluating information contained in materials.

Comprehensive Checklist

Please complete the "Critical Issues" checklist first. Then duplicate this form and use it to evaluate any materials you are using or plan to use which include DETAILED information on child passenger safety. Please make sure these issues are covered.

AIR BAG SAFETY

If existing materials have no warning about air bags, immediately add supplemental materials with air bag information and replace old materials as soon as possible.

	How to know if a vehicle has a passenger frontal air bag.
	How an air bag can kill.
	Air bag turn-off switches.

SEATING POSITION

Even if no air bag is in the vehicle, the rear seat is usually the safest position for infants and children.

	Rear-facing in rear seat.
	Child over age one in front seat with air bag.
	The center front-seat position (lap belt only).

CHILD RESTRAINT SELECTION

The "best" car seat fits the child, fits in the vehicle with its belt, and is convenient to use on every ride. Newer products are generally easier to use correctly.

	No one model is "best".
	Types of car seats.
	For the most flexibility and best potential fit, choose an infant-only restraint first.

ADJUSTING CHILD RESTRAINTS

Correct adjustment of harness straps and recline angle are very important for the safe and proper use of restraints.

	Newborn infants must ride reclined at 45 degrees to keep baby's head from dropping forward.
	Forward-facing children should ride in upright position.
	Harness slot positions.
	Adjust harness for a snug fit.
	Retainer clip holds straps on shoulders.

VEHICLE FIT AND CHILD SEAT INSTALLATION

Not all restraints fit securely in all vehicles. Fasten belt tightly and make sure seat does not move more than about one inch forward or sideward.

	Rear seat fit.
	Restraint may have more than one belt path.
	How to keep belts tight around child restraint.
	Do not secure a child restraint with an automatic shoulder belt or lap/shoulder belt attached to door.
	Forward-anchored belts can make secure installation difficult.
	Use of tether to help anchor forward-facing child restraint more securely.
	Seat cushion contours.
	Options for better installation.

SAFETY BELT FIT FOR LARGER CHILDREN

Children should use safety belts after they have outgrown booster seats and when safety belts fit correctly. Proper safety belt fit is critical.

Correct safety belt fit.

REFERRAL FOR PROBLEMS

Consumers should be advised to follow directions in both the child restraint instruction booklet and the vehicle owner's manual.

	Call manufacturer if an instruction booklet or vehicle owner's manual is not available.
	Refer users to state highway safety office or child passenger safety program.

ADDITIONAL CONSIDERATIONS

	Double-check all visuals.
	Minimize showing incorrect use or behavior.
	Make sure your audience can understand.
	Date and source are extremely important.

The National Highway Traffic Safety Administration and the National Safety Belt Coalition are committed to reducing the safety risks presented by inaccurate information. Your help in identifying published material that is inaccurate would make a tremendous difference. If you would like to assist us, fill in this simple inventory worksheet and return it to us at the address below. THANK YOU!

Instructions: Enter the information requested and your Part 1 and Part 2 scores for each publication. (Make additional copies of the checklists and worksheet as necessary.) To help us become familiar with all the material in circulation, we would also be interested in seeing the pieces you reviewed and would welcome a copy of each with your Inventory Worksheet.

Information about you:
Organization	Contact Person
Address	Telephone
	Fax
Item reviewed (title) Author or producer (org.) Date of publication (if given)	# of Boxes checked Part One			Total # of Boxes checked Part Two
	1.	2.	3.
1.
2.
3.
4.
5.

The Patterns for Life program is designed to help agencies and organizations within local communities form lasting partnerships with each other, and to provide the resources necessary to reduce the number of children killed and seriously injured each year in traffic crashes. These resources include a network of qualified child passenger safety trainers, increased opportunities for pedestrian and bicycle safety education through an extensive child passenger safety initiative, expanded training opportunities for a variety of organizations, removal of outdated materials from circulation, and the development of new and improved training materials and publications.