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

The N.C. Child Care Commission's rules committee met over the course of six months to incorporate new legal mandates into the state's childcare licensing rules and regulations. The rules committee was comprised of childcare providers, commission representatives, Division of Child Development staff and staff from the North Carolina Healthy Start Foundation. Legal expertise was incorporated as the rules were developed. The proposed rules were submitted to the Commission and are ready for the public's review and comment.

The public comment period began December 15, 2003 and continues until February 13, 2004. The proposed rules can be reviewed on-line or in the N.C. Register. Comments can be submitted in writing to the Division or expressed at the Child Care Commission meeting on February 4th. The Commission's meeting will be held at the Division of Child Development office in Raleigh, Room 300, from 5:00-7:00 PM.

Access this link to learn about the proposed rule changes:
http://ncdcd.dhhs.state.nc.us/standardreports/DCDMain_PDFs/rule_change.pdf
Click here to read a summary of the proposed rules:
http://ncdcd.dhhs.state.nc.us/standardreports/DCDMain_PDFs/summary.pdf
Click here to read the proposed rules in their entirety:
http://ncdcd.dhhs.state.nc.us/standardreports/DCDMain_PDFs/day_care_rules.pdf
Click on the link below to read House Bill 152 that became the N.C. Prevent SIDS Law:
http://www.ncleg.net/html2003/bills/CurrentVersion/ratified/House/Hbil0152.full.html
To read a media account click here:
http://www.newsobserver.com/daycare/story/3086036p-2805961c.html

Educating Childcare Providers about Reducing SIDS Risks

Dr. Rachel Moon and Rosalind Oden set out to determine if their training program, developed to educate childcare providers about SIDS and a safe sleep environment, was effective in helping providers: (1) obtain basic information and understanding of SIDS and risk reduction practices, (2) engage in the recommended behavior changes around infant sleep position, and (3) develop written sleep policies.

A sample of 96 childcare providers from both family childcare homes and centers participated in a 60-minute in-service training from a trained educator. Providers completed surveys that assessed their SIDS-related knowledge, beliefs and practices before and after their participation in the in-service. Six months later, interviews were conducted with directors or supervisors from half of the centers and homes to determine if their sleep practices or policies reflected information conveyed at the in-service.

Prior to the in-service, only one-half of the providers in this study were aware of the American Academy of Pediatrics' (AAP) recommendation that the back-sleeping position for healthy, full-term babies is preferred for reducing SIDS. Only one-third was aware of the national Back To Sleep campaign. When asked if they believed "that sleeping on the stomach places healthy infants at an increased risk for SIDS," one-third (31%) of the providers definitely believed this; 20% thought this was possibly true; 35% were unsure and 14% were either doubtful or did not believe that stomach sleeping put babies at greater risk of SIDS.

Before participating in the training, providers gave a variety of reasons for their choice of babies' sleep position. Of the caregivers who usually put infants on their backs, most did so because of SIDS risk reduction or safety reasons or to adhere to policy. For providers choosing the side-sleep position most thought it might reduce SIDS or they chose the side for other safety concerns and fear of suffocation or choking. Among the providers who were inconsistent in how they positioned babies for sleeping, most could not cite a particular reason governing their choice. However, among the inconsistent group who did state a reason, suffocation, choking and infant comfort were most commonly cited. The three providers who positioned babies exclusively on their stomachs did so because of their fears of choking and suffocation or for infant comfort.

As a result of the in-service the caregivers' awareness of the AAP recommendations increased from 48% to 78% immediately after the program and remained high (68%) six months later. Providers did favorably change their behavior by adopting recommended safe sleep practices. The number of providers who said they exclusively placed babies on their backs to sleep increased from 45% to 78%. In addition, more centers had developed a written sleep position policy as a result of the in-service (from 19% to 44%). Most importantly, these positive changes were sustained over time, based on the six-month follow-up.

Moon and Oden suggest that behavior change surrounding the adoption of safe sleep practices and creating a safe sleep environment in child care has been more difficult to alter compared to affecting parents' behavior, since the Back To Sleep campaign began. Despite changes in the participating providers' awareness about reducing SIDS, the researchers observed "the in-service did not positively affect childcare providers' belief in the relationship of prone (positioning on the stomach) and SIDS." Six months after the training the researchers did not observe a significant increase in the number of caregivers that believed stomach sleeping definitely or possibly increases the likelihood of SIDS. They conclude there is much skepticism among childcare providers about the importance of putting babies on their back to sleep.

While education and training designed specifically for childcare providers effectively increases knowledge and awareness of SIDS risk factors, prompts provider's favorable behavior change and promotes adoption of written sleep position policies, the researchers suggest something more is needed to maintain these gains. They recommend that targeted SIDS risk reduction educational opportunities for providers "be sustained through ongoing education and outreach from state and corporate licensing agencies."

Reference: Rachel Moon, MD and Rosalind Oden. Back to Sleep: Can We Influence Child Care Providers? 2003. Pediatrics. 112:4:878-882.

At this time, the use of bumper pads is not recommended and does not contribute to a safe sleep environment. As a best practice, the American Academy of Pediatrics, the National Center for Health and Safety in Child Care, the Consumer Product Safety Commission and the First Candle/National SIDS Alliance suggest that bumper pads be removed from the crib.

First Candle/National SIDS Alliance is convening a task force to examine the soft bedding issue, especially as it relates to bumpers. Data will be gathered on SIDS and accidental deaths associated with bumpers; a risk analysis associated with and without the use of bumpers will be conducted; and standards will be developed. This information will be shared through the ITS-SIDS Project as it becomes available.

A SIDS Parent's Story

Nancy Maruyama, R.N., executive director at SIDS of Illinois and mother of Brendan (6-1-85/10-18-85) who died of SIDS while in child care, shares her perspective about the use of bumper pads in the following article.

SIDS of Illinois does NOT advocate the use of ANY type of bumper pads. Bumper pads were used when I was a baby (in the late 1950s) because the slats in the cribs were so far apart, the baby could potentially fall out. Bumpers were used to help keep the baby in the crib. Since 1984, when it became national law that the slats in cribs be no more than 2 3/8" wide, there was no longer a need for bumper pads.

Parents are concerned that the baby's "soft spot" will be injured if they don't use a bumper pad. There is actually no danger to the soft spot on the baby's head. The soft spot is a very thick membrane and infants are not able to get enough momentum to hit that particular area against the crib with any force. They would truly have to be going at ramming speed in order to injure the soft spot.

The likelihood of arm or leg fractures resulting from an infant's limbs slipping under the pads and getting stuck in the slats is possible but is not likely to occur. As a mother whose infant son was found unresponsive with his face against the bumper pads, I would much rather have had an infant with a broken arm or leg, than a dead infant.

In my particular case, I believe that Brendan's auto resuscitory response did not work and the carbon dioxide rebreathing issue was a factor in his death. Brendan died in 1985, before we knew about "Safe Sleep for Baby" and all the risk reduction information we have today.

We continue to stress to our new parents, nurses, childcare providers, grandparents and anyone who cares for infants to DECORATE THE ROOM, NOT THE CRIB.

Editor's Note: This article was prompted by recent advertising for crib bedding and bumper pads. We would like to remind you that the N.C. Back to Sleep Campaign for SIDS Risk Reduction does not recommend bumper pads. The only thing in the crib while a baby sleeps should be a blanket that has been securely tucked in to prevent it from covering the baby's face.

On November 25, 2003, the First Candle/SIDS Alliance announced a new partnership with the Consumer Product Safety Commission (CPSC) to get important recall information for infants' and children's products into the hands of parents and caregivers. A new web site: www.Recalls.gov enables consumers' easy access to product recall information in English and Spanish.

Health and safety professionals working with consumer groups that do not have access to the Internet will be able to downloadable posters and other consumer information.

Editor's Note: Find recalled products by their product type, description or company name. Use the www.Recalls.gov "simplify search" feature by typing in a key word. I searched "baby" to access product information designed for babies and the list included toys, rattles, cribs, portable cribs, playpens, walkers, clothing and many other items. This is a handy tool to help you make sure baby items in your child care are safe.

The ITS-SIDS Project has been underway for a year and a half, and has made steady progress with its goal to introduce a safe sleep standard of care in North Carolina's licensed childcare facilities. The training goal of reaching 8,000 childcare providers in two years has already been exceeded in 18 months! The demand for training skyrocketed primarily due to the recently passed SIDS law mentioned earlier in this newsletter.

The ITS-SIDS Project has been expanded to incorporate a third phase of training to reach childcare providers, owners/operators/directors, lead infant teachers, substitutes, and volunteers counted in the child to staff ratio that care for infants 12 months of age or younger. Phase 3 will run concurrently with Phase 2 for the remainder of this fiscal year and continues through August 2005.

To-date:

~ 9,173 childcare providers trained
~ 573 trainings scheduled or completed
~ 144 ITS-SIDS trainers trained

A hearty THANK-YOU to all of the ITS-SIDS trainers who have assisted their community's childcare providers in taking important steps to lower SIDS risks and to create safer sleeping conditions for the babies in their care. We look forward to another successful year!

ITS-SIDS Training Required

Childcare providers are reminded that the ITS-SIDS training is the SIDS-related training required by the new licensing rules. To learn who is the certified ITS-SIDS trainer in your county, contact your childcare health consultant, Child Care Resource and Referral, Smart Start Partnership, the local cooperative extension service or check our web site. A list of certified ITS-SIDS trainers by county is posted at http://www.nchealthystart.org/its-sidstrainer_list.html. To access the ITS-SIDS training schedule by county click on http://www.nchealthystart.org/its-sidstrainingschedule.html.

We are currently recruiting ITS-SIDS Trainers for Phase 3 to be trained in March 2004.
Contact [email protected] to apply.