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Deputy Prime Minister Dr Wan Azizah Wan Ismail has reminded Malaysians that the government will be making child car safety seats mandatory from January 2020. To facilitate this, Dr Wan Azizah also unveiled a guidebook on how the regulations will be implemented.

The guidebook, created by the Malaysian Institute of Road Safety Research (MIROS), provides information about identifying and installing child restraint system (CRS) - the technical term for child seats. This new requirement is the product of a gradual introduction of improved safety regulations for keeping children safe while in motor vehicles.

As it stands, all CRS purchased must conform to the United Nations (UN) Regulation No. 44 (ECE R44/04) and Regulation No. 129 (ECE R129) as these are the only types that have received approval for use in Malaysia.

What child car seat to buy

Identifying certified child car seats is very simple. Approved seats will be labelled with the relevant UN regulations. The example provided by the guidebook shows them as follows:

Kategori produk mengikut berat atau tinggi

Product category according to height or weight

Nombor kelulusan yang diberi

Approval number

Peraturan UN R44 atau R129

UN regulation R44 or R129

Negara yang meluluskan Peraturan UN

UN regulation country of origin

These seats will also be labelled with a QR code that provides more information on how to use them. This code also leads to a site with instructions on how to properly install it and the recommended age and height of the child it is meant to protect.

This QR code will lead to a site with further information on: a) the UN Regulation R44 or R129 certification, b) installation instructions, and c) suitably of use according to the height and weight of the child.

Selecting a child seat

A CRS or child car seat should be chosen according to the weight and height of the child. The MIROS guidelines break these down into four groups (based on UN guidelines) divided along these lines. Age is not necessarily a factor in which seat to use as children of the same age can differ greatly in terms of size.

Group 0/0+

- Weight below 9kg
- Recommended for weight below 13kg
- Height below 83cm

Rear facing infant car seat

Group 1

- Weight between 9 and18 kg
- Minimum height 71cm

15 months to 4 years

Forward facing infant seat

Group 2

- Weight between 15 and 25kg
- Minimum height 100cm

4 to 7 years

Child booster seat with five-point harness

Group 3

- Weight between 25 and 36kg
- Height up to 135cm

6 years and older

Child booster seat

Some of these categories overlap, but as a rule of thumb infants and children under the age of one year old should be using rear facing seats. This will then progress into toddler booster seats with five-point harnesses, and then eventually a regular booster seat that makes use of the vehicle's own seat belt system.

These guidelines also remind parents to avoid installing rear facing CRS in the front passenger seat if the vehicle has an airbag system. If there is a need to place the child seat there, then it is a legal requirement that the airbag first be deactivated.

How to buy a child seat

Due to the nature of child seats, it is best to buy them in person. This is to ensure that you can check on the quality of the device, and to be able to clearly check the UN regulation compliance labels. It is an unfortunate reality that not every child seat sold on the market conforms to established safety requirements (even if some manufacturers label them correctly).

For the most part, it is recommended that parents visit a physical store - even if their intention is to buy online. This allows them to examine the sturdiness of the car seat and determine if it can be installed in their car.

There is a wide range of car seats designs out there and they are not standardized to fit all cars. In order to get started, read up on other users' recommendations on parenting sites such as asianparent.com and motherhood.com.my or through parenting social media groups to decide on your budget and type of car seat system fits your lifestyle and budget.

Malaysian Institute of Road Safety Research (Miros) research officer Nurulhana Borhana suggest that parents check for a valid QR label sticker from Miros in addition to the UN regulation orange label, cautioning that cheap units may also illegally attach the labels.

"When it comes to safety issues, every parent should not compromise. However, not all quality CRS sets are sold at RM1,000 per unit.

"There are actually CRS sets which are in compliance with the safety standards and tests but priced as low as RM150 to RM300," she told Bernama.

Most e-commerce merchants do not list the compliance of their products, making it difficult to gauge whether they meet UN regulations so, there is no harm in window shopping first and then looking for the same model through an e-commerce site. Here's a basic guide on starting prices of various models available online.

Many young parents also consider using car seats from their siblings and close relatives whose own children have outgrown them. This can save quite a bit of money but just check to make sure the seat complies with the new regulations and is not damaged which can compromise safety.

As you can see, a car seat can become a big-ticket item to purchase but ensuring the safety of your newborn begins the first 12 months of life's journey requires an upfront investment in a reliable car seat.

Act now

The new regulations were announced by Transport Minister Anthony Loke in 2018, and are set to be enforced in January 2020. This leaves you with less than two months to shop for and install a car seat for your child.

In all fairness, most parents are already responsible enough to be using child seats. These regulations lean more towards improving the safety standards of the equipment being sold, ensuring that the seats do everything they can to keep the little ones safe if something unfortunate happens.

It also means that parents now have a globally recognised safety standard for reference when looking up which car seats to buy. The government will also be enforcing the UN regulations on imports, which should help ensure that you won't have to look too far to find a compliant child seat.

More information about the new child seat regulations can be downloaded from here.

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Compulsory Child Car Seats Next Year; What You Need to Know

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Deputy Prime Minister Dr Wan Azizah Wan Ismail has reminded Malaysians that the government will be making child car safety seats mandatory from January 2020. To facilitate this, Dr Wan Azizah also unveiled a guidebook on how the regulations will be implemented.

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Abstract

This article examines the diffusion of U.S. state child passenger safety laws, analyzing over-time changes and inter-state differences in all identifiable features of laws that plausibly influence crash-related morbidity and mortality. The observed trend shows many states' continuing efforts to update their laws to be consistent with latest motor vehicle safety recommendations, with each state modifying their laws on average 6 times over the 30-year period. However, there has been a considerable time lag in knowledge diffusion and policy adoption. Even though empirical evidence supporting the protective effect of child restraint devices was available in the early 1970s, laws requiring their use were not adopted by all 50 states until 1986. For laws requiring minors to be seated in rear seats, the first state law adoption did not occur until two decades after the evidence became publicly available. As of 2010, only 12 states explicitly required the use of booster seats, 9 for infant seats and 6 for toddler seats. There is also great variation among states in defining the child population to be covered by the laws, the vehicle operators subject to compliance, and the penalties resulting from non-compliance. Some states cover only up to 4-year-olds while others cover children up to age 17. As of 2010, states have as many as 14 exemptions, such as those for non-residents, non-parents, commercial vehicles, large vehicles, or vehicles without seatbelts. Factors such as the complexity of the state of the science, the changing nature of guidelines (from age to height/weight-related criteria), and the absence of coordinated federal actions are potential explanations for the observed patterns. The resulting uneven policy landscape among states suggests a strong need for improved communication among state legislators, public health researchers, advocates and concerned citizen groups to promote more efficient and effective policymaking.

Keywords: Child passenger safety law, child restraint, seat belt law, public health law, traffic safety, policy diffusion, United States

Introduction

In the U.S., nearly 250,000 children are injured every year in car crashes, and approximately 2,000 die from their injuries. ( NHTSA, 2011) Moreover, the child passenger fatality rate in the U.S. is at least double that of other comparable wealthy nations, including Sweden, Japan, U.K., Italy and Norway. ( OECD, 2004) Most of these fatalities and injuries are preventable. ( Winston, Kallan, Elliott, Xie, & Durbin, 2007) Studies have demonstrated that the proper use and placement of child restraint devices substantially reduces harm to child passengers in vehicle crashes. ( Durbin, Chen, Smith, Elliott, & Winston, 2005; Valent, McGwin Jr., Hardin, Johnston, & Rue III, 2002; Zaloshnja, Miller, & Hendrie, 2007)

In the late 1970s, the U.S. public's increasing awareness of the high rates of morbidity and mortality for child passengers resulted in rapid proliferation of state laws on the issue. Between 1977 and 1985, all 50 states adopted one or more laws aimed at reducing harm to infants and child passengers by requiring the use of some sort of child restraint device. However, subsequent scientific findings showed the need for a more concerted effort to ensure proper seating position and restraint device usage ( P. Agran, Castillo, & Winn, 1990; P. F. Agran, Dunkle, & Winn, 1985; Bull, Stroup, & Gerhart, 1988; Carlsson, Norin, & Ysander, 1991; Kahane, 1986; Roberts & Turner, 1984; Ross & Gloyns, 1986; Sprigg, 1985; Teret, Jones, Williams, & Wells, 1986).

Beginning in the 1990s, National Highway Traffic Safety Association (NHTSA), as well as professional associations like American Academy of Pediatrics (AAP), have developed child passenger safety standards and guidelines that cover a wider range of child passenger safety issues and better protect children from injuries. Among other things, they emphasized the importance of three types of safety practices in protecting child passengers: (1) device-based restraints that are tailored to the age/size of individual child passengers; (2) rear seating, and; (3) seatbelt wearing of minors who have outgrown child restraint devices but are still in need of supervision to comply with seatbelt requirements. However, the federal government's direct intervention to promote enactment of child restraint laws has been limited to providing modest financial incentives ( Richardson & Houston, 2009) U.S. Congress would not likely enact federal law that regulates the behavior of vehicle operators in all 50 states. While Congress may have power to legislate such law under the Commerce Clause, it does not have constitutional power to "commandeer... state legislative or executive official" to enforce federal law, Printz v. U.S., 521 U.S. 898 (1997). The federal government, however, can encourage or pressure states with funding or grants. The recent Moving Ahead for Progress in the 21st Century Act (MAP-21) is one of such examples, where the federal government continues its effort to provide grants to states that encourage and enforce the public's proper use of child restraints. But the monetary amount involved is relatively small and there have not been any penalties or diversionary tools such as conditioning the provision of the existing federal funding on a state's passage of child passenger safety laws.

In the absence of a strong federal intervention, the 50 states' laws on child passenger safety largely vary in their features, which provides a valuable opportunity to evaluate which part of the existing evidence was codified as a statutory requirement and whether some aspects were diffused more widely or rapidly than others. The aim of this study is to utilize this opportunity by conducting a systematic analysis of child passenger safety laws across 50 states in the U.S. and examining the possibilities and limits of public health policy diffusion.

In the 1960s, Everett Rogers introduced the idea of diffusion of innovation ( Rogers, 1962) Political scientists have since conducted numerous empirical studies examining policy diffusion across states and theorizing new diffusion trends ( Green, Ottoson, García, & Robert, 2009; Meseguer & Gilardi, 2009; Shipan & Volden, 2012). Regarding child passenger safety, Teret's 50-state analysis of the scope of child restraint requirements in 1986 and Winston's 50-state evaluation of booster seat laws in 2007 are the main two studies exploring the variation in state child passenger safety laws that we have identified ( Teret et al., 1986; Winston et al., 2007). We did not locate any previous research comparing the diffusion of multiple child passenger safety laws or examining state-to-state variation of such laws over time.

The U.S. child restraint laws provide a useful example of policy diffusion for the following reasons: (1) the problem is severe, with children accounting for 21% of traffic fatalities worldwide ( WHO, 2008) and motor vehicle crashes being the leading cause of death for children under 14 in the U.S. ( NHTSA, 2010); (2) the policy effect is highly visible-empirical evidence shows that, if correctly installed and used, child restraints reduce deaths among child passengers by 70-80% ( Rice & Anderson, 2009; Richelderfer, 1976) and that mandatory child restraint laws and their enforcement increase the use of such devices ( Winston et al., 2007); (3) with the exception of limited federal funding incentives, it has been largely up to each state to legislate and enforce laws regulating vehicle operators' child passenger safety behavior ( Richardson & Houston, 2009); and (4) the continuing evolution of child passenger safety science and technology has presented state policymakers repeatedly with new knowledge that required the existing law to be changed, thus making this policy domain particularly suitable for investigating the relationship between changes in knowledge of best practices and state adoption of such knowledge.

Methods

We conceptualized this study with the purpose of documenting the evolution of three major categories of state laws and their features directly aimed at changing vehicle operators' behaviors to reduce the incidence and severity of harms to children in motor vehicle crashes. This study covers all 50 states in the U.S. over the period of 1978 until 2010. In determining when the law came into existence, we used the effective date, rather than the date of enactment.

For the purposes of this study, we defined "children" as those belonging to the age group 0-16 and included the three types of laws that have in the past been recommended by AAP or CDC Task Force on Community Preventive Services (Task Force), namely laws requiring the use of child restraints, seat belt laws targeting minor passengers and laws mandating child passengers to be in rear seats ( AAP, 1996, 2002; Services, 2001) We measured and coded every identifiable substantive feature of the laws, including who needs to comply, what devices should be used, and how to use such devices. We also measured features of the laws associated with enforcement, including the amount of penalties and enforcement priority. The features we coded and the variables we used are discussed in the results section.

In order to investigate the child passenger safety laws of 50 states, the research team conducted a multi-source-based survey of state laws enacted between 1970 and 2010. Primarily using the current state statute databases in Westlaw (a U.S. proprietary online legal database), the research began with the then most up-to-date versions of the child passenger safety statutes. The following search phrase was used: "child! infant! baby youth /20 restrain! seat! belt! booster passenger." We obtained the citations for prior versions of the statutes through Westlaw historical notes, and retrieved the full texts of those previous versions by utilizing additional online legal databases such as Westlaw, LexisNexis, and HeinOnline, and contacting law school libraries and state congressional libraries. For the statutes that had existed at some point during the 40-year period but were repealed or recodified in a different place in the statutory code, we used the same search phrases in the Westlaw historical state statute databases. As the final process for ensuring the reliable capture of the earliest relevant laws, we used the session laws database on HeinOnline.

Following the first round of data collection, supervising researchers, who were licensed attorneys, conducted an initial review to define a list of variables for which each law would be coded. Based on the list, a protocol was developed to code the legal text into quantifiable data. Coding was conducted using a Google.doc web form, which guided coders through a series of coding questions that elicited information about the features of the law. This interface - which integrated the codebook and the data input sheet into an online questionnaire format -facilitated simultaneous coding at multiple sites. In addition, its structured and path-dependent nature seemed to increase the accuracy of coding by eliminating human error and reducing fatigue involved in inputting data into spreadsheets directly.

We periodically reviewed coding results and compared the data to the initial review summary chart and original legal texts. In addition, we compared the coding results to the law summary produced by NHTSA ( Decina, Lococo, Ashburn, Hall, & Rose, 2008) and Insurance Institute for Highway Safety, a U.S. non-profit research organization funded by auto insurers. ( IIHS, 2011) We discussed and resolved any inaccuracies and inconsistencies in team discussions with coders. When the data were updated in summer of 2011, we created a Microsoft Access database to catalogue the legal texts and to provide a query-able resource. To assess inter-coder reliability, an independent coder, masked to the previous coders' results, coded a randomly selected set of laws representing 15% of the total data. Rates of divergence for each variable were recorded as well as overall rates of divergence for all variables. Results showed high inter-rater reliability with rates of divergence no greater than 3% (Cohens Kappa=95%). Most divergences occurred in the coding of effective dates.

Results

uses child restraint law as an example and presents the framework that we developed to categorize different aspects of the law and contains a summary of variables that were deduced from this framework. Our coding process revealed extensive variation among states in the way the laws were written, leading to 194 variables for all types of laws we examined (87 for device law, 55 for rear seating law, and 52 for minor seatbelt law). These variables can be collapsed into five categories for each law: which children are protected under the law; what action should be taken in order to comply with the law; how the law is enforced; what the penalties are for non-compliance; and who should comply with the law/who is exempted from doing so. Similar categorical breakdown was observed for rear seating law and minor seatbelt law.

Table 1

Which children are protected under the law

Age of child a

The age range at which a child passenger is required to use a child restraint device/rear seat/seat belt

Minimum and maximum ages for infant seat, toddler seat, booster seat, and non-specified general child restraint (8 variables)

Weight of child a

The weight range at which a child passenger is required to use a child restraint device/rear seat/seat belt

Minimum and maximum weights for infant seat, toddler seat, booster seat, and non-specified general child restraint (8 variables)

Height of child a

The height range at which a child passenger is required to use a child restraint device/rear seat/seat belt

Minimum and maximum heights for infant seat, toddler seat, booster seat, and non-specified general child restraint (8 variables)

What action should be taken in order to comply with the law

Type of restraint device required

Whether the law specifies a device type (such as a booster seat) depending on the child's age, weight and/or height

Yes/No binary variable for existence of explicit infant, toddler and booster seat laws, as well as implicit laws for each (6 variables)

How the law is enforced

Primary enforcement vs. secondary enforcement

Whether law enforcement officers can stop the vehicles solely based on noncompliance with child passenger safety laws or not

Yes/no binary variable for child restraint law (1 variable)

What the penalties are for non-compliance

Type of penalty

Whether there is a fine, license points, insurance points, or mandatory education requirement

min. fine, max. fine, min. license points, max. license points, min. insurance points, max. insurance points, existence of mandatory education for the violation (7 variables)

Who should comply with the law and who is exempted from doing so

Exemptions

See Table

See (23 variables)

The nature of the requirements in these categories has changed over time. For instance, in defining the child population covered by laws, all states initially only used age ranges. As researchers found that a child's weight and height were more accurate measures of children's size, states have begun to incorporate them into the laws. While the validity of using heights and weights as child passenger categorization criteria has recently been questioned ( Zonfrillo, Elliott, Flannagan, & Durbin, 2011), the prevailing recommendation during the study period was to incorporate such distinctions into laws. ( AAP, 2002; Arbogast, Moll, Morris, & Winston, 2001; NHTSA, 2000)

Likewise, the type of restraint device that operators are required to use has evolved from a generic "child restraint device" to multiple specific devices for different age/weight/height sub-groups of children (i.e. a rear-facing infant seat, forward-facing child restraint (FFCR) and booster seat). In addition, states have increasingly referenced safety standards and appropriate installation methods.

describes the changing trend in the number of states with each type of child passenger safety laws from 1978 until 2010. The dark straight line displays the rapid proliferation of the earliest version of child-restraint laws in the late 1970s and early 1980s. Rear seating laws and minor seatbelt laws (represented as the thin double line and the light stitched line in ) were adopted far more slowly. As of 2010, 35 states required seatbelt use for minor passengers and only 14 states required rear seating of child passengers.

Since this initial wave of legislation, states have continuously refined their policies in light of emerging safety research. The dark stitched line provides an example of one such effort, representing the number of states that switched from a simple age-based categorization to an age, weight and/or height-based distinction, as recommended by the scientific community during our study period as a better way of ensuring protection of child passengers. ( Ogden, Carroll, Curtin, Lamb, & Flegal, 2010; Pollack, Xie, Arbogast, & Durbin, 2008; Trifiletti et al., 2006) While the number of states using weight and/or height-based criteria has steadily increased since 1994, it plateaued at 39 in 2009 and remained so in 2010.

Another example of states' effort to incorporate new scientific findings has been to specifically designate the use of an infant, FFCR or booster seat for a child based on his age and/or size. The early version of child restraint laws had simply required that a child passenger under certain age should be restrained, without specifying which type device should be used. The dotted line represents the number of states that explicitly mandate the use of a booster seat for a child passenger over the age of 4, 40 lbs and/or 57 inches. While the number of states that merely require child passengers of a booster seat age/size to wear any child restraints has increased to 34 in 2010 (shown in the medium dark grey line), those explicitly mandating the use of booster seats are much fewer in number (13 in 2009, 12 in 2010). Likewise, while all 50 states have required the use of child restraints for passengers under the age of 2 since 1986, only 9 states explicitly require the use of infant seats.

shows the number of states engaging in legislative activities relating to child passenger safety laws in a given year. While there has been consistent legislative activity during the study period (1978-2010), the trend line graphs generally have a U shape, with the initial surge of legislative moments occurring from 1982 until 1984, and a second peak following around 2004 and 2005. The first wave was mostly related to creating laws that required the use of non-specific "child restraint devices" for all children under a certain age. The second wave in legislative changes was the result of the states' attempt to add provisions relating to rear seating and minor seat belt use, and specifying required devices by age, weight and/or height. On average, states modified their child passenger safety laws six times over the 30-year period.

Interestingly, while certain states enacted one type of child passenger safety laws earlier than others, these same states were not forerunners for other types of the laws. shows the first ten states that adopted each type of child passenger safety laws. Apart from New Mexico and Wisconsin, no other states stand out as consistent early adopters. In addition, among the nine states that explicitly required the use of booster, infant and/or FFCR seats in 2010, only four of them (Washington, Colorado, South Carolina and Tennessee) enacted rear seating and minor seatbelt laws. None of them were ahead of the curve in doing so..

Table 2

Another feature of the evolution of child passenger safety laws is the variety and complexity of exemptions. As shown in , 14 exemptions were identified for 50 states' child restraint device laws (very similar exemptions also existed for rear seating laws and minor seat belt laws). As of 2010, Oregon and Rhode Island had none of the 14 exemptions, whereas Arizona, Hawaii, Massachusetts, Montana and Ohio had the largest number of exemptions (approximately 7). The latter group of states generally limited the application of the device law to non-commercial passenger vehicles. They also enforced the laws only for those driving on highways (except Arizona) and exempted any vehicle operator whose vehicle had insufficient space to install devices for all of child passengers (except Ohio).

Table 3

Exempts non-parent operators

Yes/no binary variable re: whether the law covers non-resident operators; the same for resident operators (2 variables)

Exempts non-vehicle owners (rental vehicle operator)

Yes/no binary variable (1 variable)

Exempts commercial passenger vehicles (such as taxies, buses, day care center vehicles, vehicles for hire)

Yes/no binary variable (1 variable)

Exempts non-passenger commercial vehicles (such as trucks, delivery vehicles)

Yes/no binary variable (1 variable)

Exempts vehicles that are not designed to be operated on highways (such as motorcycles, electronic personal mobility vehicles, recreational vehicles)

Yes/no binary variable re: whether the law covers vehicles not designed to operate on highways; the same for those designed to operate on highways (2 variable)

Exempts vehicles that were originally manufactured without seat belts

Yes/no binary variable re: whether the law covers vehicles manufactured without seatbelts; the same for those manufactured with seatbelts (2 variables)

Exempts vehicles with capacity of more than X number of passengers

Yes/no binary variable re: whether the law covers vehicles with capacity of more than 6-8 passengers; the same for those with smaller capacity (2 variables)

Exempts vehicles that were not being operated on highways at the time

Yes/no binary variable re: whether the law covers vehicles not on highways; the same for those on highways (2 variables)

Exempts children for whom a doctor or a commissioner decided that the use of a restraint device is impractical (often due to the children's disability)

Yes/no binary variable (1 variable)

Exempts vehicle operators if more than one child was in a vehicle and there was not enough space/rear seats/seat belts to accommodate multiple child restraint devices (often, but not always, based upon the condition that the maximum number of those who could be seated in child restraint devices were seated in such devices)

Yes/no binary variable (1 variable)

Penalties for violation of child passenger safety laws consist of fines, license points and/or insurance points. Sometimes the laws required mandatory attendance of traffic safety education. The fine amount varied from $0 (i.e. no fine) to $2000, often subject to judicial sentencing discretion. Taking the median dollar amount in case the laws set a range, the average amount of fine for the initial offense as of 2010 was $46.51 and the same for the second offense was $65.31. In some states, these fines could be waived if one could later produce a proof of purchase of a child restraint device. Some states allowed substituting payment of the fine for attendance of traffic safety education courses.

Discussion

Our study identified and analyzed all of the major substantive features of multiple child passenger safety laws, thus marking a distinctive approach from the existing evaluations that define policy as merely dichotomous measures of a single law's presence or absence. This detailed approach allowed us to examine the change in 50 states' adoption pattern of specific features of laws, such as height/weight distinction in defining child population or explicitly mandating the use of infant, FFCR, or booster seats. The analysis reveals the complexity of the diffusion of knowledge about motor vehicle safety and the states' decision to adopt such knowledge into their policies, especially when there is no strong federal requirement or incentive for them to do so.

One of the notable aspects of child restraint laws is the long time lag between the publication of new scientific knowledge and its incorporation into state legislation. The first child restraint model for crash protection was developed in 1968, and NHTSA promulgated the first child restraint safety specification for manufacturers in 1970. Pediatricians and other experts called for the government's attention to the issue as early as in 1971. ( W. F. Rowley, Jr., E. Lariviere, & C. W. Dietrich, 1971; W. F. Rowley, E. Lariviere, & C. W. Dietrich, 1971; Shelness & Charles, 1975) Empirical research supporting the use of child restraint devices was published in a number of articles throughout the 1970s ( Arnberg, 1978; Christophersen, 1977; Scherz, 1976; Williams & Zador, 1977) Yet, the first child restraint law was passed in Tennessee in 1978 and the adoption of device laws by all 50 states did not occur until 1986.

One possible explanation of the delay in the first wave may be that states were awaiting the evaluation of the law in the early adopter states, given that, as shown in , a surge occurred soon after reports of the positive health outcome of child restraint law in the early adopter states (Tennessee and Rhode Island). ( A. F. Williams & J. A. K. Wells, 1981; A. F. Williams & J. K. Wells, 1981) Alternatively, this surge may be related to NHTSA's revised child restraint safety standard for manufacturers that went into effect in 1981. The amended rule significantly strengthened the safety requirements for child restraints, mandated the 30 mph crash test and distinguished rear-facing and forward-facing directions based on children's size.

However, the delay in the second wave of legislative change cannot be explained in the same way. The change could have occurred as early as the mid-1990s when the technology became more sophisticated to provide different types of device for children of different ages, heights and/or weights. In response to the increasing scientific evidence supporting the importance of using correct devices for child passengers, AAP issued a child safety seat guideline in 1996, where it recommended the use of infant seats for children under the age of 1 or 20 lbs, FFCR for children older than 1 and weighing 20-40 lbs and booster seats for those who have outgrown FFCR. ( AAP, 1996) In addition, the Congress enacted the TEA-21 Act in 1997, which provided a 10-15 million grant over 2 years to states that required a child to be restrained in a proper device. However, as can be observed in , the increase in the number of states incorporating weight/height distinction was marginal throughout the 1990s and the number of states explicitly mandating infant, FFCR or booster seats remained very low (fewer than 5). It was not until 2001 that the adoption rates of these laws picked up. The turning point began in the early 2000s, around the time CDC Task Force "strongly" recommended states to adopt laws mandating the use of age and size appropriate child restraints ( Services, 2001), NHTSA and AAP guidelines were updated with similar emphasis ( AAP, 2002; NHTSA, 2000), and NHTSA promulgated new regulation requiring passenger vehicles manufactured after September 2002 to be equipped with anchors and tethers for child restraint devices. However, exactly how these events precipitated this outcome is beyond the scope of this study.

When the state laws that do not designate a specific device and merely refer to a generic "child restraint" are included in the analysis (so long as the laws cover the age/weight/height group that is supposed to use each device type), a more rapid increase in the number of states with implicit booster seat laws (i.e. any child restraint device laws covering children who should use booster) can be observed around 2003, soon after the publication of articles reporting the relative paucity of booster seat use ( Durbin, Kallan, & Winston, 2001; NHTSA, 2002; Ramsey, Simpson, & Rivara, 2000) and after the Congress enacted Anton's Law in 2002, which required NHTSA to establish booster seat safety standards. The number of booster seat laws that cover children up to 8 years old, 80 lbs or 57 inches picked up around 2006-2007, soon after the passage of the SAFETY-LU Act that established the $25 million grant for states with child restraint laws covering children up to eight years old, perhaps indicating the importance of federal government's monetary incentives to enable a nationwide state law change. However, even in such a case, the rate of increase fell far behind the first wave and the number of states explicitly requiring the use of a booster seat remained low throughout the period.

The lag time is particularly long for rear seating laws. The safety benefits of rear seating were reported by scientists as early as 1977. ( Williams & Zador, 1977) After a series of reports on the danger of airbag-associated injuries to children riding in the front seat ( CDC, 1995, 1996a, 1996b; Hollands, Winston, Stafford, & Shochat, 1996), NHTSA launched a campaign encouraging rear seating of child passengers in 1996. ( Kindelberger & Starnes, 2003) AAP's updated guideline also emphasized the importance of rear seating. ( AAP, 1996) Yet, only two states, Delaware and Rhode Island, responded in 1997. As of 2010, only 14 states require rear seating of child passengers.

In contrast, the number of states with 21-year minimum legal drinking age (MLDA) increased from 17 in 1984 to 50 in 1988, 4 years after Congress passed the National MLDA Act conditioning states' enactment of such law to the continued full provision of the highway funds. ( Wagenaar, 1993) Similarly, the number of states with the law limiting the legal blood alcohol concentration to 0.08% increased from 19 in 2000 to 50 in 2006, 6 years after Congress passed an act tying each state's enactment of such laws to the continued provision of federal highway funds. ( Sleet et al., 2011)

One possible explanation for the persistent time lag is differential legislative capacity among states. As Shipan and Volden pointed out, "about a dozen states do not pay their legislators any annual salary at all, beyond covering per diem expenses; some legislatures do not meet for more than a few months every year or two; and many do not hire extensive legislative staff. Such circumstances profoundly influence policy diffusion processes." ( Shipan & Volden, 2012) Poor legislative infrastructure could lead to a delay in investigating and discovering new policy innovation, and even after such discovery, a legislative backlog may result in a longer time for a bill to be submitted, accepted, debated, voted and signed into law.

An additional explanation for the slow adoption of some child passenger laws may be the absence of credible laws to emulate. Even if scientific evidence support the effectiveness of a policy, state legislators' attention to the issue may not occur at a significant level or materialize into legislation until such laws have shown to be successful or at least come into existence in another state ( Moynihan, 2008; Volden, 2006). Given that very few states adopted some of these laws (rear seating mandates, for instance), they presented very few models for emulation. As to the reasons for the large number of exemptions and wide state-to-state variation in providing such exemptions, there are several hypotheses to suggest. First, despite the media's increasing attention to child passenger safety over the past decades, legislators may not be equipped with the most up-to-date information on technology or scientific research in this area, leading to confusion about what actions should be taken to better protect child passengers. Second, the observed differences may have been driven, at least in part, by lobbying and advocacy, where the power struggle among different stakeholders, such as device manufacturers, commercial vehicle operators and parents, may have led to wide variation in the direction of legislative developments. Third, the lack of nationwide authority and guidance may have further contributed to the state-level variations.

Limitations

As with all studies, this one has limitations. First, this study is limited to state statutes, thus not accounting for the potential impact of common laws, regulations, or non-law-based programs by sub-local governments or agencies. Second, despite extensive efforts to collect the full texts of all versions of the laws, there were some difficulties tracking down all features of state laws because some of them were not included in the same code. For instance, whether violations result in a penalty of insurance points was not provided in the text of the child passenger laws themselves but in other statutes or court rules. Thus, our results may miss some provisions of laws if they were spread across different parts of the code. Some laws could not be located using our sources and are thus absent from our data, including Connecticut's pre-1985 infraction rules, Idaho's infraction rule, and Florida's court rules concerning insurance demerit points. Third, this study is limited to a descriptive analysis of states' legislative action and does not include determinant analysis. Nor does it statistically test any specific theories of diffusion. These are important areas for future research. Fourth, while we use the term "child passenger safety law" to refer to the set of laws examined in this study, they do not constitute the complete universe of laws that aim to promote child passenger safety. Likewise, the major publications and federal interventions plotted on our Figures do not represent all events that may have influenced the legislative activities. Lastly, this study is based on law "on the books." Further empirical evaluations of the effect of these laws "on the street" would need to account for numerous other factors like enforcement intensity, education programs, and engineering innovation improving passenger safety.

Conclusions

This study identified child passenger safety laws as a complex, multifaceted set of interrelated policy interventions that have seen innovative changes over the last 40 years. The results suggest that the development of specificity of the laws tended to coincide with changes in scientific knowledge about best practices. However, uptake of new laws and the revision of existing laws to reflect the latest policy-relevant knowledge have been far from up-to-date or uniform. The slow learning-based diffusion, complexity of the state of science, and lack of strong federal guidance could be hypothesized as contributing factors. Uneven policy diffusion suggests that communication channels between public health researchers and local legislators should be improved to promote efficient evidence-based policymaking.

​

Acknowledgement

This work was supported by a grant (#67150) from the Robert Wood Johnson Foundation Public Health Law Research Program and a grant (1R01AA021436-01) from the National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism. We gratefully acknowledge the contribution of NYU and Temple University law and public health student research assistants.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

IIHS. Highway Safety Research and Recommendations: Child Restraint Laws. 2011 from [http://www.iihs.org/laws/childrestraint.aspx. Google Scholar]

Kindelberger J, Starnes M. Washington, D.C.: 2003. Moving Children from the Front Seat to the Back Seat: The Influence of Child Safety Campaigns. (DOT HS 809 698). Retrieved from [http://www-nrd.nhtsa.dot.gov/Pubs/809-698.PDF. Google Scholar]

Shipan CR, Volden C. Policy Diffusion: Seven Lessons for Scholars and Practitioners. Public Administration Review. 2012 [Google Scholar]

WHO. World report on child injury prevention. In: Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Rahman AKM, Rivara F, Bartolomeos K, editors. Geneva: WHO; 2008. [Google Scholar]

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Child Passenger Safety Laws in the United States, 1978-2010: Policy Diffusion in the Absence of Strong Federal Intervention

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This article examines the diffusion of U.S. state child passenger safety laws, analyzing over-time changes and inter-state differences in all identifiable features of laws that plausibly influence crash-related morbidity and mortality. The observed trend shows many states' continuing efforts to update their laws to be consistent with latest motor vehicle safety recommendations, with each state modifying their laws on average 6 times over the 30-year period.

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Washington updates car-seat law to better protect children

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Gov. Jay Inslee today signed into law updated regulations on car-seat and booster-seat use in Washington state. The updated law will go into effect on Jan. 1, 2020. UW Medicine pediatrician Beth Ebel studies transportation safety at Harborview's Injury Prevention and Research Center. Under the revised law: Children under age 2 must use rear-facing car seats.

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Children are much more vulnerable than adults in a car so taking time to make sure you use the right child seat (restraint) or booster correctly, could save your child's life. Drivers and passengers are more likely to be killed or seriously injured when they don't wear a seat belt.

Child car seats, restraints and the law

You must use the right car seat for your child in:

The driver must make sure that any child under 14 years old uses a seat belt or the right child restraint. Any child restraint used must conform to EU safety standards that is either Regulation 44.04 or Regulation 129 (also known as i-Size seats).

All children up to 135cm (approximately 4ft 5in) in height, or up to 12 years of age (whichever occurs first), must use a suitable child restraint - that is, one that is suitable for your child's height or weight.

There is a fixed penalty fine of £60 and three penalty points for not using the right child restraint. If the case goes to court, this could increase to a maximum fine of £500 for any occupant anywhere in the car.

Birth to three years of age

Children under three years of age must use a suitable child restraint. There is only one exception:

a child under three may travel unrestrained in the rear of a taxi or a minibus if the right child restraint isn't available

​Rear-facing baby seats must not be used in a seat protected by a front air-bag unless the air-bag has been deactivated.

From three to 12 years old

In vehicles where seat belts are fitted, children from three years to 12 years and up to 135cm in height (about 4ft 5in) must use the right child restraint.

Three exceptions allow these children to travel in the rear of the vehicle with the use of an adult seat belt:

in a taxi if the right child restraint is not available

for a short distance, in an unexpected necessity - if the right child restraint is not available

where two occupied child restraints in the rear prevent the fitting of a third child seat and no suitable child restraint is available for use in the front passenger seat

There is also an exception for children with a a medical certificate saying that it is not advisable on medical grounds to wear a seat belt.

A child taller than 135cm must wear a seat belt where one is fitted.

Children 12 to 13 years or over 135cm in height

Children aged 12 or 13 years or over 135cm (regardless of age) in height must wear a seat belt where one is fitted.

Summary of seat belt and child restraint requirements

Choose the right child car seat for your child

You should choose a child car seat or restraint based on your child's height or weight.

There are two European standards for child restraint systems. These are Regulation 44 and Regulation 129 (or i-Size). Seats manufactured to either standard will have a label showing a capital 'E' in a circle - as shown in the picture.

The label will indicate which standard the child car seat meets - Regulation 44 or Regulation 129 (i-Size). Regulation 44 child car seats are based on weight with an age recommendation. Regulation 129 (or i-Size) child car seats are based on height/ length and have a maximum weight. The label will tell you the weight or maximum height/ length the child car seat is designed for.

If you choose a Regulation 129 (i-Size) child car seat you will need to check that your car is fitted with ISOFIX anchorage points. These child car seats are marked with the i-Size symbol which is shown in the picture on the right. If you are not sure, check with the manufacturer.

Regulation 129 will replace Regulation 44 seats. Until then, seats manufactured to either standard are safe and legal when used properly.

Check the label to make sure it's suitable for your child and only use it in keeping with the manufacturer's instructions.

When buying a child restraint, if possible, try it in your car before you buy. Not all seats will fit or be suitable for your car. If you plan to use your child car seat in more than one car it is important to check that it fits other cars as well. Speak to the shop sales adviser who will give you advice and may show you how to fit the restraint correctly.

ROSPA website has information and tips on choosing and using child car seats.

Types of child restraints

A child restraint is the collective term for rear facing baby seats, forward facing child seats, booster seats and booster cushions.

Manufacturers may use different names and some products may cover more than one weight or height so it is important to read the label.

Regulation 44 child car seats

Regulation 44 child car seats are based on weight with an age recommendation and are divided into five weight groups:

Regulation 129 child car seats

Regulation 129 child car seats are based on length / height, have a minimum weight and are also known as i-Size seats. Child car seats approved according to Regulation 129 will be phased in over time. In the first phase (which is already in place) manufacturers are producing child car seats suitable for children up to 105cms - around four to four and a half years of age:

the first stage i-Size child car seat is designed for children from birth up to 15 months and must be rear-facing - this will accommodate a child with a length/height up to about 83cm

in addition to the size range (length/ height) a maximum weight - up to which the child car seat can be used - is shown - so it is also important that you know the weight of your child

each child restraint manufacturer will specify the length/ height range and maximum child weight for their product

it is possible to keep your child in a rear facing seat beyond 15 months to 105cm length/ height - forward facing child car seats can be used from 15 months but you should delay this as outlined below under 'Use the restraint correctly'

it is important to check the label to make sure the child car seat is suitable for the length/ height of the child using it and that you observe the maximum weight allowed

Use the restraint correctly

Every year too many children are killed or seriously injured on the roads - often because they are not properly restrained when travelling in a car. So make sure you understand the law and give your child the best possible protection.

Many seat experts believe that it's better and safer to keep your child in the lowest group seat for as long as possible. This means staying in their current stage seat until the maximum weight or height limit is reached. Because children grow and develop at different rates it is important to keep a watch on your child's height and weight to make sure that they don't move up a stage too early or too late.

You must only use a child restraint if your car's seat belt has a diagonal strap, unless the child restraint is:

specifically designed for use with a lap seat belt only

fitted using ISOFIX anchor points

check the label to make sure the child car seat is suitable for your child's weight and height

fit the child restraint properly - follow the manufacturer's instructions

every trip - allow time to get the child comfortably strapped in

where using an adult belt to secure the restraint - make sure it passes through all the right slots

make sure that the child restraint is tight in the adult seat

make certain that the adult seat belt buckle is not bent over or resting on the child restraint frame

never fit a rear-facing restraint with an active airbag in front of it

check the vehicle handbook and follow the advice about children and airbags - where fitted

deactivate any front airbags before fitting a rear-facing (baby) restraint in a front seat

never modify the restraint or adult seat belt to make it fit

never fit a child restraint in side-facing seats

Booster seat rules - no change for existing seats

rules are now in force for backless booster seats (booster cushions)

​the rules apply to both Regulation 44 and Regulation 129 i-Size backless booster seats

this means that manufacturers are not allowed to introduce new models of backless booster seats (booster cushions) for children shorter than 125cm, or weighing less than 22kg

this change to technical standards means that the range of products available on the market will be better suited for younger children

however the rules do not affect existing models of booster seats and booster cushions - parents can continue to use existing models available -provided that the labelling indicates that they are suitable for their child

the key message is to check the label of the backless booster seat (booster cushion) that you are using or looking to buy - if the label shows that it is suitable for the child that you are carrying - you will not be breaking the law

More useful links

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Child car seats, restraints and seat belts

# data[].attributes.attachment_link.description
Children are much more vulnerable than adults in a car so taking time to make sure you use the right child seat (restraint) or booster correctly, could save your child's life. Drivers and passengers are more likely to be killed or seriously injured when they don't wear a seat belt.