Infant/Toddler Safe Sleep & SIDS Risk Reduction in Child Care NEWSLETTER

May 1, 2004 is a historic date for childcare providers and child health and safety advocates. Within nine months after Governor Easley signed House Bill 152 into law childcare licensing rules supporting the legal mandate will go into effect on that date. Last month's newsletter featured links to an earlier version of the proposed rules. ITS-SIDS trainers and providers should make note of several important changes reflected in the final rules version. Those changes impacting the ITS-SIDS training are as follows:

• The ITS-SIDS training must be completed within four months of hire or within four months of the rules becoming effective.
• ITS-SIDS training must be renewed every three years.
• The sleep position waiver will not be posted on the baby's crib since it may contain confidential medical information. Instead, a notice will be posted on the crib stating the alternative sleep position and stating where the waiver is filed.
• "Tummy time" for awake infants was added to the family childcare home rules.
• The prohibition on smoking in family childcare homes was expanded. Rule .1720(f) now says the operator shall not use tobacco products at any time children are in care. Smoking or the use of tobacco products shall not be permitted indoors while children are in care, or in a vehicle when children are transported.

Note: DCD offers the following clarification for the tobacco-related rules for childcare homes.

The first sentence of Rule .1720(f) applies specifically to the family childcare operator - the person taking care of the children - and prohibits him/her from using tobacco products while children are in care. This means whether he/she is inside, outside, in the car with the children, etc. However, this is the operator's private residence and other household members may be around while children are in care. So the second sentence of Rule .1720(f) is broader and prohibits anyone (not just the operator) from smoking or using tobacco indoors while children are in care, or in a vehicle when children are transported. This would allow a household member to go outside and use tobacco while the caregiver and children were inside.

The impetus to address tobacco in this issue of the ITS-SIDS newsletter comes from two sources. First, in light of the limitations on tobacco use in child care outlined in the revised N.C. childcare licensing rules, addressing secondhand smoke is timely. Secondly, on their evaluations some ITS-SIDS trainers requested more information about smoking. The research on smoking or secondhand smoke exposure pertains primarily to the results of parents' smoking and is not specific to childcare settings. However, this review helps deepen our understanding about ways in which tobacco use affects infant/child health and development.

What is Secondhand Smoke?

Secondhand smoke, a toxic soup of 4,000 chemicals, is made up of airborne particles and gases. Nicotine, an addictive drug in tobacco, is one of many particles found in cigarette smoke. Carbon monoxide, ammonia, formaldehyde and several known cancer-causing chemicals are in secondhand smoke. Keep in mind that infants' airways are small and they breathe rapidly so the impact of secondhand smoke is compounded for them.

There is clear and convincing evidence that secondhand smoke causes lung cancer, heart disease, respiratory illnesses and low birthweight births. Low birthweight is a leading cause of infant death and disability and also a risk factor for SIDS. Furthermore, babies born with low birthweight experience delays in motor and social development more often than those born with a normal weight.

Smoking and SIDS Link

While smoking during pregnancy triples the chances of Sudden Infant Death Syndrome (SIDS), researchers admit it is hard to tease out the separate impact of a pregnant woman's smoking from secondhand smoke exposure once the baby is born.

Nicotine, present in cigarette smoke, can act as a stimulant or a depressant on the brain. Nicotine is has been shown to reduce babies' ability to wake from sleep if the mother smoked during pregnancy but it also contributes to other sleep disorders. At 2-3 months of age smokers' babies awoke less often from quiet sleep regardless of whether they were sleeping on their stomach or their back (1). This may help to explain why infants born to mothers who smoked during pregnancy may have an increased risk for SIDS, particularly during the age range when SIDS occurs most often.

Research into secondhand tobacco smoke exposure alone, not complicated by maternal smoking during pregnancy, shows that breathing tobacco smoke is linked to SIDS. Secondhand smoke more than doubles the SIDS risk. Higher concentrations of nicotine have been found in the lung tissue of infants that have died from SIDS compared to infants dying from other causes. As one would expect, the levels of nicotine and its metabolic by-product, cotinine, were greater in the lung tissue of infants that came from a smoking environment.

Breathing secondhand smoke by pregnant non-smokers also impacts infants' health and is associated with more frequent hospitalizations for affected children after they are born.

The loss of life to SIDS is a most severe consequence of tobacco use and smoke exposure, but it is the day-to-day results of breathing tobacco smoke that most of us are more likely to encounter.

Harmful Effects of Secondhand Smoke Confirmed

Even among well-intentioned parents that try to lower their children's exposure to tobacco smoke by using a fan when smoking or smoking by a window, the harmful consequences of secondhand smoke are not eliminated. In fact, even among young children whose parents smoked outdoors cotinine (the chemical created when nicotine is processed in the body) was present in their bodies (2).

Illness

Secondhand smoke has a major effect on children's developing respiratory and immune systems according to researchers with the American Academy of Allergy, Asthma and Immunology (3). Secondhand smoke increases children's risk of developing allergies (allergic rhintis) and allergy sensitivity, respiratory infections and wheezing. Secondhand smoke causes coughing, more severe asthma attacks and more frequent asthma attacks.

A genetic predisposition also plays a part in a child's allergenic responses to tobacco smoke. If one or both parents smoked during pregnancy or during the child's first decade of life and if one of the parents had allergies the risk of allergic sensitivity to secondhand smoke almost doubled. If both parents had allergies this tobacco smoke allergic sensitivity risk increased seven times. The likelihood of wheezing followed a similar pattern. If both parents had allergies and children breathed secondhand smoke, wheezing was five times more likely to occur. The risk doubled if only one parent had allergies (4).

The American College of Chest Physicians reports that exposure to secondhand smoke in childhood increases the likelihood of asthma among adult non-smokers and the chances of becoming a smoker.

Developmental Delays

Secondhand smoke contributes to developmental and cognitive delays for young children. Scores on tests for cognitive development among two-year olds were lower for those exposed to smoke at home compared to those that don't breathe secondhand smoke (5). For families with lower socio-economic status, the effect of secondhand smoke on brain development is worse.

References:
(1) Horne, R.S., D.Ferens, et al. Effects of maternal smoking, sleeping position and sleep state on arousal in healthy term infants.
Neonatal Ed. 2002:87(2):F100--5.
(2) Medline Plus. http://www.nlm.nih.gov/medlineplus/news/fullstory_16953.html as reported by Reuters Health Infomation based on an article in Pediatrics, April 2004.
(3) PACT News. www.endsmoking.org/archives/200403/20040324asthma.html March 24, 2004.
(4) American College of Chest Physicians. Study reveals link between asthma and childhood exposure to environmental tobacco smoke.
Press Release September 11, 2001.
(5) National Institutes of Health. Study shows effects of prenatal exposure to second-hand smoke greater for socioeconomically disadvantaged children. Press Release March 15, 2004.

The Environmental Protection Agency (EPA) has begun a campaign for Smoke-Free Homes, based on findings that infants exposed to secondhand smoke have increased health problems. Information is available in English and Spanish.

• EPA: http://www.epa.gov/iaq/ets/
• Smoke-free Homes: http://www.epa.gov/iaq/ets/pledge/index.html
• For schools: http://www.epa.gov/iaq/schools/tfs/guidef.html

The ITS-SIDS Project has turned another corner with the implementation of Phase 3. During the last two weeks of March 64 additional ITS-SIDS trainers were certified for 43 counties.

At the end of March the training goal of 14,500 providers, set for August 2005, had almost been reached.

• Phase 1 ITS-SIDS trainers have trained 7,528 childcare providers and have scheduled or completed 406 ITS-SIDS trainings in a little more than one year since they were trained!
• Phase 2 ITS-SIDS trainers have reached 5,964 childcare providers and have completed or scheduled 378 trainings since October 2003, just five months ago!
  

To-date:

~ 13,492 childcare providers trained
~ 784 trainings scheduled or completed
~ 208 ITS-SIDS trainers trained

Reminders:

1. If you are from a Non-Exempt agency, make sure you submit to the ITS-SIDS Project your Authorization Form and the Outline Form for each training you schedule within the required time frame. Approval from DCD is required before you can conduct the ITS-SIDS Training. Follow the instructions in Chapter 6 of the ITS-SIDS Training Manual.

2. Date Change - all rosters and evaluations should continue to be sent to the ITS-SIDS Project through August 2005.