A summit to improve investigation of sudden infant death

According to the studies conducted by Dr. Rachel Moon and colleagues, 20% (approximately 500) of all SIDS fatalities in the United States continue to occur in daycare environments. Half (approx. 250) occur during the first week of placement, and one-third of that number (approx. 80+) occur on the very first day the infant is placed in the new situation.

These deaths are occurring in cots and not in any type of co-sleeping/bed-sharing situation , and they are practically all occuring during the daylight hours.

It takes a great deal of imagination to be able to accept that ignorance or disregard of B-T-S protocol on the parts of the new care providers, is the reason that the fatality statistics are so astronomically skewed.

SIDS occurs in deep quiet sleep (DQS) and for a variety of reasons sleeping babes put smiles on all our faces, do they not?
Keeping them sleeping contentedly sucking away on bottles of sweetened watery/juicy concoctions regularly succeeds in achieving the goal... and that perhaps is the well-meaning and completely unwitting factor that tips the scales in the direction of an innocent infant sleeping forever.Sadly it was never intended to be considered even a possibility, and far less the consequence of the best of intentions.

Ed O'Hagan
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References:

Infant sleep position in licensed child care centers.

Gershon NB, Moon RY.

Department of General Pediatrics, Children's National Medical Center, Washington, DC 20010, USA.

OBJECTIVE: To determine 1) familiarity of child care centers with American Academy of Pediatrics (AAP) recommendations regarding infant sleep position, 2) predominant infant sleep positions in child care settings, and 3) child care policies pertaining to sleep position for infants less than 6 months of age. DESIGN: A descriptive, cross-sectional telephone survey including the age and number of infants cared for, infant sleep positions currently in use, and details regarding reasons for sleep position policies. PARTICIPANTS: All licensed child care centers caring for infants less than 6 months of age in Washington, DC, and Montgomery and Prince Georges Counties in Maryland. RESULTS: Out of 137 centers in these areas that accept infants less than 6 months of age, 131 completed the survey. Only 57% (75) of the centers were aware of recommendations regarding infant sleep position. Infants were placed prone in 49% (64) of the centers and 20% (26) of the centers positioned infants exclusively in the prone position. Of the centers, 75% (98) did not have a written policy regarding sleep position. Most common reasons for placing infants in the prone position included child comfort, fear of choking, and guidance by the parents of the infants. Centers that used the prone position exclusively cared for significantly fewer infants on average than centers that never or only sometimes placed infants prone. CONCLUSIONS: Almost half (43%) of licensed child care centers surveyed in the greater Washington, DC area were unaware of the association between sudden infant death syndrome (SIDS) and infant sleep position. Child care centers aware of prone positioning as a SIDS risk were less likely to place infants to sleep in this position, with many such centers avoiding prone positioning entirely. However, it was common for centers aware of the SIDS risk to still place infants prone if directed to do so by parents or if concerned about child comfort. Further educational efforts directed toward child care providers are needed.

Publication Types:
Comparative Study

PMID: 9200363 [PubMed - indexed for MEDLINE]

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2: Pediatrics. 2000 Aug;106(2 Pt 1):295-300. Related Articles, Links

Sudden infant death syndrome in child care settings.

Moon RY, Patel KM, Shaefer SJ.

Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

BACKGROUND: The incidence of sudden infant death syndrome (SIDS) in the United States has decreased with decreased prone sleeping. Extrapolating from Census Bureau data, approximately 7% of SIDS should occur in organized child care settings (ie, child care centers or family child care homes). However, 2 states have reported higher rates of SIDS in child care. OBJECTIVES: To determine the percentage of SIDS deaths occurring in child care settings, and to ascertain associated factors. DESIGN: A retrospective study of SIDS deaths from January 1995 through June 1997 was conducted. Data were abstracted from SIDS databases in 11 states. Characteristics of SIDS cases occurring in child care settings, including sleep position, were compared with those occurring in the care of parents. Univariate and multiple logistic regression analyses were performed. RESULTS: A total of 1916 SIDS cases were analyzed for this study. Of these deaths, 20.4% occurred in child care settings. Compared with deaths in the care of parents, those occurring in child care settings were more likely to occur on weekdays between 8:00 AM and 4:00 PM; infants were older; not black; and their mothers were more educated. Infants in child care were more likely to be found prone in univariate analysis, but the association was not significant in multiple logistic regression analysis. However, in multiple regression analysis, infants in child care were more likely to be last placed prone or found prone, when the usual sleep position was side or supine. CONCLUSION: A large proportion (20.4%) of SIDS cases occur in child care settings. Factors associated with SIDS in child care settings include older age, race, and highly educated parents. Previous studies have reported that unaccustomed prone sleeping puts infants at high risk for SIDS; this characteristic was found to be associated with SIDS in child care and may partly explain the high proportion of SIDS cases in child care settings. Parents must discuss sleep position with any caretakers of their infants. In addition, further efforts to educate child care providers about the importance of supine sleep for infants must be ongoing.

Publication Types:
Research Support, Non-U.S. Gov't

PMID: 10920154 [PubMed - indexed for MEDLINE]

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3: Pediatrics. 2000 Sep;106(3):576-80. Related Articles, Links

Infant sleep position policies in licensed child care centers after back to sleep campaign.

Moon RY, Biliter WM.

Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

BACKGROUND: Since the Back to Sleep (BTS) campaign was initiated in 1994, the rate of prone sleeping has decreased to approximately 20%. However, child care centers may have an increased rate of prone sleeping in infants. In 1996, a study of licensed child care centers demonstrated that 43% were unaware of the association between sudden infant death syndrome (SIDS) and prone sleeping and that 49% positioned infants prone. OBJECTIVE: To determine effectiveness of a mailing from the BTS campaign to licensed child care centers by assessing the following: 1) child care center awareness of the recommendations of the American Academy of Pediatrics regarding infant sleep position and 2) implementation of the recommendations of the American Academy of Pediatrics in child care center practice. DESIGN: A descriptive, cross-sectional survey of licensed child care centers in the metropolitan Washington, DC, region. All licensed child care centers caring for infants <6 months old in Washington, DC, and Montgomery, Prince Georges, Howard, Anne Arundel, Frederick, and Charles Counties in Maryland were recruited for the study. RESULTS: Out of 236 eligible centers, 172 completed the survey. Seventy-five percent (129) of the centers were aware of recommendations regarding infant sleep position. Infants were placed prone in 27.9% of centers, although only 2.9% placed infants exclusively in the prone position. The most common reasons for avoiding prone position entirely were SIDS risk reduction and licensing regulations. Half of the centers had a written policy regarding sleep position. Twenty centers who were aware of the dangers of prone sleeping continued to placed infants prone at least some of the time, largely because of parental request. Only 56.9% of centers had heard of the BTS campaign despite the mass mailing. The mailing resulted in policy change for 14 centers. CONCLUSIONS: Since 1996, the percentage of licensed child care centers in the greater Washington, DC, area that are aware of the association between SIDS and infant sleep position has increased from 57% to 75%. In addition, the rate of placing infants prone in these centers has declined from 49% in 1996 to 27.9% in this study. When child care centers are aware of the risk of prone sleeping, the most likely reason for continued prone placement is parental request. Although media and mailings have been largely effective in communicating BTS information to many child care centers, nonprone positioning is not universal among child care providers. Additional educational efforts toward child care providers and parents remain necessary.

Publication Types:
Multicenter Study

PMID: 10969105 [PubMed - indexed for MEDLINE]

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4: Pediatrics. 2001 May;107(5):1029-36. Related Articles, Links

Examination of state regulations regarding infants and sleep in licensed child care centers and family child care settings.

Moon RY, Biliter WM, Croskell SE.

Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

BACKGROUND: Twenty percent of sudden infant death syndrome (SIDS) occurs in child care settings. Although the incidence of SIDS in the United States has decreased with increased awareness of the risks of prone infant sleeping, smoke exposure, soft bedding, and unsafe sleep environments, avoidance of these risk factors is not universally practiced in child care settings. Advocacy through state child care regulatory agencies and legislative bodies may be effective in more widespread awareness and avoidance of risk factors. OBJECTIVE: To determine what individual state regulations for licensed child care centers and family child care settings exist regarding: 1) sleep positions for infants under 6 months old, 2) crib safety, 3) bedding safety, and 4) smoking in the facilities. DESIGN: A descriptive survey of regulations for licensed child care centers and family child care settings in the 50 states and the District of Columbia. RESULTS: Fifteen states use regulations adopted before publication of the first policy statement of the American Academy of Pediatrics on infant sleep position and SIDS in 1992. Six states require child care centers to place infants nonprone. Sixty-three percent of states require cribs in child care centers to meet at least 1 safety standard, and 45.1% require this in family child care homes. Six states have provisions limiting the use of soft bedding in child care centers, and 4 have such bans for family child care homes. Seventy-one percent of states prohibit smoking in child care centers during hours of operation; 17% of states have similar requirements for family child care homes. CONCLUSIONS: Many states use child care regulations that were written before the initial policy statements of the American Academy of Pediatrics regarding safe sleep environments for infants. Even those more recently adopted regulations do not adequately address sleep safety for infants. Pediatricians need to become more proactive in promoting safety regulations in child care. Adoption of new regulations can aid in education of child care providers and, thus, improve the safety for infants in child care.

PMID: 11331682 [PubMed - indexed for MEDLINE]

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5: Pediatrics. 2003 Oct;112(4):878-82. Related Articles, Links

Back to sleep: can we influence child care providers?

Moon RY, Oden RP.

Department of General Pediatrics, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

OBJECTIVE: Despite the fact that 20% of sudden infant death syndrome (SIDS) deaths occur in child care settings, many child care providers continue to be unaware of the association of SIDS and infant sleep position and/or are misinformed as to the risks and benefits of the various sleep positions. The objective of this study was to determine whether an educational program for child care providers regarding SIDS and safe sleep environment is effective in 1) providing basic information and understanding regarding SIDS risk reduction practices, 2) changing child care provider behavior, and 3) promoting development of written sleep position policies. METHODS: We designed a 60-minute educational in-service for child care providers, to be led by a trained health educator. All providers who attended the in-service were asked to complete surveys before and after the in-service. Surveys assessed provider knowledge, beliefs, and practices. A 6-month follow-up interview was conducted with child care centers that had providers participating in the in-service. RESULTS: A total of 96 child care providers attended the educational in-service. Providers who were using the supine position exclusively increased from 44.8% to 78.1%. This change in behavior was sustained, with 85% of centers placing infants exclusively supine 6 months after the intervention. Awareness of the American Academy of Pediatrics recommendation of supine as the preferred position for infants increased from 47.9% to 78.1%, and 67.7% of centers continued to recognize supine as the recommended position 6 months later. The percentage of centers that reported written sleep position policies increased from 18.8% to 44.4%. CONCLUSIONS: A targeted educational in-service for child care providers is effective in increasing awareness and knowledge, changing child care provider behavior, and promoting development of written sleep position policies. This change is sustained over at least a 6-month period.

Publication Types:
Evaluation Studies
Research Support, Non-U.S. Gov't

PMID: 14523180 [PubMed - indexed for MEDLINE]

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6: Pediatrics. 2005 Oct;116(4):972-7. Related Articles, Links

Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001.

Moon RY, Sprague BM, Patel KM.

Division of General Pediatrics and Community Health, Goldberg Center for Community Pediatric Health, Washington, DC, USA. rmoon@cnmc.org

OBJECTIVE: A total of 20% of sudden infant death syndrome (SIDS) cases in the 1990s occurred in child care settings. This is much higher than the 8% expected from Census Bureau data. Factors that were associated with child care SIDS included older age; white race; older, more educated mothers; and unaccustomed prone position. Since these findings, much emphasis has been placed on promoting a safe sleep environment in child care. The objectives of this study were to determine the proportion of SIDS occurring in child care in 2001 and to assess risk factors for SIDS in child care. METHODS: We conducted a retrospective review of all SIDS deaths that occurred in 2001 in 13 US states. Information regarding demographics, SIDS risk factors, and child care arrangements were collected and analyzed. Deaths that occurred in child care were compared with deaths that occurred during parental care. RESULTS: Of 480 deaths, 79 (16.5%) occurred in child care settings. Of these child care deaths, 36.7% occurred in family child care homes, 17.7% occurred in child care centers, 21.3% occurred in relative care, and 17.7% occurred with a nanny/babysitter at home. Infants in child care were more likely to be older and to die between the hours of 8 am and 4 pm and less likely to be exposed to secondhand smoke. There was no difference in usual, found, or placed sleep position between child care and home deaths. Approximately one half of the infants who died of SIDS in both settings were found prone, and 20% of deaths in both settings were among infants who were unaccustomed to prone sleep. CONCLUSIONS: The proportion of SIDS deaths in child care has declined slightly but still remains high at 16.5%. Infants in child care are no more likely to be placed or found prone and no more likely to be on an unsafe sleep surface. Educational efforts with child care providers have been effective and should be expanded to unregulated child care providers. In addition, there may be other, yet-unidentified factors in child care that place infants in those settings at higher risk for SIDS.

Publication Types:
Research Support, Non-U.S. Gov't

PMID: 16199710 [PubMed - indexed for MEDLINE]

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7: Pediatrics. 2006 Jul;118(1):73-83. Related Articles, Links

State child care regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign.

Moon RY, Kotch L, Aird L.

Division of General Pediatrics and Community Health, Goldberg Center for Community Pediatric Health, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010, USA. rmoon@cnmc.org

BACKGROUND: Despite overall decreases in sudden infant death syndrome deaths and prone sleeping, the proportion of sudden infant death syndrome deaths that occurs in child care settings has remained constant at approximately 20%. In 2003, the American Academy of Pediatrics' Healthy Child Care America program launched its own Back to Sleep campaign to promote the Back to Sleep message for those who care for young children. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of the first 2 years of the Healthy Child Care America-Back to Sleep campaign in improving child care regulations by assessing the inclusion of the elements of a safe sleep environment in the individual state regulations for child care centers and family child care homes. METHODS: We examined regulations available in October 2005 for licensed child care centers and family child care homes in the 50 states and the District of Columbia for specific regulations pertaining to (1) sudden infant death syndrome risk-reduction training for child care providers, (2) infant sleep position, (3) crib safety, (4) bedding safety, (5) smoking, and (6) provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care. RESULTS: Since 2003, when the Healthy Child Care America-Back to Sleep campaign began, 60 of the 101 state regulations for either child care centers or FCCHs have been revised. More than half of these regulations written since 2003 mandate a nonprone sleep position and restrictions on soft bedding in the crib, and the change in these regulations since 2003 is statistically significant. However, of the 101 existing state regulations, only 49 require that infants sleep nonprone, 18 mandate sudden infant death syndrome training for child care providers, 81 have > or = 1 crib safety standard, and 43 restrict soft bedding in the crib. Only 4 regulations require that parents be provided with sleep policy information. CONCLUSIONS: The initial 2 years of the Healthy Child Care America Back to Sleep campaign have been successful in promoting safe infant sleep regulations. Efforts must continue so that safe sleep regulations exist in all jurisdictions.

PMID: 16818551 [PubMed - indexed for MEDLINE]