 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1029-1036
,, and
Medical University of South Carolina
Charleston, SC 29425
From the * Department of General Pediatrics and Adolescent
Medicine, Children's National Medical Center, Washington, DC;
Department of Pediatrics, George Washington University School of
Medicine and Health Sciences, Washington, DC; and the § Department of
Pediatrics, University of Utah, Salt Lake City, Utah.
 |
ABSTRACT |
|---|
Top
Abstract
Methods
Results
Discussion
References
|
|---|
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. Key words: crib safety, prone position, sleep position, smoking regulations, sudden infant death syndrome, child care, intervention.
It is estimated that 20% of sudden infant death syndrome
(SIDS) occurs in child care settings.1 Since the initial
recommendation of the American Academy of Pediatrics (AAP) to place all
healthy infants on their backs or sides to reduce the risk of
SIDS,2 and the subsequent educational campaign, Back to
Sleep (BTS), the incidence of SIDS in the United States declined 40%
to 0.69 per 1000 live births in 1996 from 1.2 per 1000 live births in 1992.3 Although this campaign has led to changed behavior
among parents, many child care providers continue to be unaware of the
need for SIDS risk reduction.4,5
In the United States, the number of women in the labor force with
children younger than 6 years of age has increased from 2.9 million in
1960 to 10.3 million in 1996.6 As the number of working
mothers has increased, so has the number of children in child care.
From 1977 to 1992, the number of licensed child care centers (CCCs)
more than doubled, rising from 25 000 to 51 000.7
According to the US Census Bureau in 1994, 17% of infants under 1 year
of age were attending organized child care,6,8
approximately one half in CCCs (defined as licensed nonresidential facilities that provide care for >10 children),9,10 and
one half in family child care homes (FCCH; defined as care of 6 or
fewer children in a nonrelative caregiver's home).9,10
It is well-established that the risk of SIDS can be reduced with
supine sleep position, safe cribs, avoidance of soft bedding, and
eliminating exposure to secondhand smoke.11-14 The AAP,
in its most recent policy statement regarding SIDS,14 has
emphasized the need for including all of these elements in a safe sleep
environment for infants. Infants may spend up to 50 hours/week in the
care of a noncustodial adult.1 The most common reason for
child care providers not to incorporate these safe sleep elements is
lack of awareness.5 Education and new information directed
toward child care providers are often effective in changing
behavior.5 Education of child care providers often is
accomplished through state-licensing agencies, mailings, seminars, and
enforcement of regulations.5
Regulations for licensed CCCs and FCCHs are determined by individual
state agencies. These state regulations are an important means of
helping to ensure safety in child care. It is unknown how many state
regulations require CCCs and FCCHs to provide the elements of a
safe sleep environment for infants. The purpose of this study is to
determine the inclusion of the elements of a safe sleep environment in
the individual state regulations for CCCs and FCCHs. The key elements
of safe sleep environment, as described by the AAP14
include: 1) supine sleep position for infants under 6 months old, 2)
safety of cribs, 3) avoidance of soft bedding, and 4) a smoke-free
environment.
This study examined existing regulations of licensed
CCCs and FCCHs in the 50 states and the District of Columbia. The
regulations were collected from individual state documents available in
February 2000 and data available from the 1999 Child Care Center
Licensing Study15 and the 1998 Family Child Care Licensing
Study.16 Information was collected regarding specific
regulations pertaining to: 1) infant sleep position, 2) crib safety, 3)
bedding safety, and 4) smoking. Two of the investigators examined all 3 sources of documents. A regulation was considered to be in force if it was mentioned in any 1 of the 3 documents.
All 50 states and the District of Columbia have designated
agencies that set regulations regarding child care facilities. Only 8 jurisdictions do not have separate regulations for licensed CCCs and
FCCHs.17-24 Regulations for licensed CCCs were enacted
from 1985 to January 2000, and those for FCCHs were enacted from 1985 to January 2000 (Tables 1 and
2). A total of 17 states
(33.3%)17,18,25-40 use regulations for either licensed
CCCs or FCCHs that were written before the AAP initial 1992 policy
statement regarding positioning and SIDS.2
TABLE 1 TABLE 2
METHODS
Top
Abstract
Methods
Results
Discussion
References
RESULTS
Top
Abstract
Methods
Results
Discussion
References
Summary of State Regulations for Licensed Child Care Centers
Summary of State Regulations for Family Child Care Homes
Infant Sleep Position Regulations (Tables 1 and 2)
Six CCC regulations (11.7%)22,41-45and 2 FCCH regulations (3.9%)22,46 stipulate a back or side position for infants under the age of 6 months. One state stipulates that CCC providers physically check on sleeping infants every 30 minutes specifically "because of the risk of SIDS,"39 whereas CCCs in 5 other states (9.8%) are required to check sleeping infants frequently.21,45,47-49 Seven states (13.7%) have similar requirements that FCCH providers physically check on sleeping infants at intervals ranging from every 15 minutes to every 2 hours.21,50-55 One jurisdiction specifies that the FCCH provider must constantly supervise any infant sleeping in a playpen.56 Forty states (78.4%) have no regulations addressing sleep position or the supervision of sleeping infants for CCCs; 42 states (82.3%) have no FCCH regulations.
Crib Safety Regulations (Tables 1 and 2)
The AAP recommends a crib conforming to the safety standards of the Consumer Product Safety Commission,57 states that infants should not be placed on waterbeds, sofas, soft mattresses, and other soft surfaces, and recommends avoidance of bed sharing among children.14 All states address 2 issues of crib safety in both CCCs and FCCHs: the prohibition of stacking cribs and only 1 infant per crib (although some states allow sharing of cribs within a FCCH if separate bedding is used). In the CCCs, 63% (32) of the states have at least 1 other specific regulation pertaining to crib safety,20-23,27,28,31,32,38,43-45,47-49,58-74 whereas 22 states (43.1%) have regulations for FCCHs.20,21,28,50-54,56,75-88 Cribs in most states include full-sized cribs, portable cribs, and potentially playpens. Playpens as a sleeping surface are banned in CCCs in 5 states (9.8%)24,31,45,65,89 and FCCHs in 3 states (5.9%).24,56,81,85 Thirty-nine percent of states (20)18,23,32,36,37,41-43,47,48,63,66-70,73,90-92 allow CCCs and 29.4% (15) of states allow FCCHs25,26,50,54,55,75,76,79,80,82,84-86,93,94 to use playpens for sleeping.
Many states have adopted the Consumer Product Safety Commission (CPSC) standards for cribs (Table 3)57 by specifically referring to agency standards, stating federal requirements, or citing the specific standards (eg, slats less than two and three-eighths inches apart). However, 10 of the 51 jurisdictions provide no specific regulations regarding crib specifications17,30,36,37,90,91,95-99 and 9 (17.6%)18,24,39,41,42,89,92,100,101 use nonspecific (eg, safe, sturdy, usable condition, or age-appropriate) terms to address crib safety in the CCC setting.
|
In the regulations regarding cribs in FCCHs, 16 states (31.3%) require FCCHs to use a snug-fitting mattress.20,21,28,50,53,54,56,75-79,81-85 Two states (3.9%) do not allow sleeping on a waterbed if the child is <3 years old,87,102 whereas another state prohibits the use of a futon for sleep for children under 13 months of age.102
Bedding Regulations (Tables 1 and 2)
The AAP and CPSC recommend avoidance of soft bedding (quilts, comforters, sheepskins) and objects (pillows, stuffed toys) in the infant's sleep environment,14,103 because they have been implicated as risk factors for SIDS.104,105 Six states (11.7%) prohibit the use of a pillow by infants in licensed CCCs,24,37,45,61,66,97 and 4 states (7.8%) ban them in FCCHs.24,50,77,102 One state specifically prohibits the use of comforters in CCCs45 and no states prohibit them in FCCHs. In the FCCH and CCC regulations, 3 states (5.9%) each require the use of crib bumpers for infants younger than 6 months of age, usually if substandard cribs are used.32,63,69,79,83,102
Smoking Regulations (Tables 1 and 2)
Two states (3.9%) do not mandate any limitations on smoking in licensed CCCs.17,30 Thirty-six of the states (70.5%) prohibit smoking in the licensed CCC during hours of operation.19,20,22,24,28,31,32,36-39, 41-45,48,49,59-66,69,71,72,74,89,91,92,95,96,100,101 Smoking is allowed within designated smoking areas in the CCC regulations of 9 states (17.6%),21,27,36,47,58,67,68,90,98,99 whereas only 3 states (5.9%) mandate a designated smoking area in FCCHs.34,40,84 Smoking is prohibited only when in direct contact with the children or in food preparation areas in 4 CCC regulations (7.8%).18,23,70,73 Eleven states (21.6%) also ban smoking while CCC children are in vehicles.24,41-43, 66,69,71,89,91,92,101 No regulations require parental notification of smoking status in the CCC.
In FCCH regulations, smoking policies often are dependent on the presence of the children within care. Seventeen states (33.3%) prohibit smoking during the hours of FCCH operation.19,22,25,29,35,46,55, 75-78,83,93,94,106-108 Twenty-seven states (52.9%) prohibit smoking in the direct contact of children, in areas of care while children are present, and/or in areas of food preparation.18,20,21,23,24,26,28,33,50-54,56, 79-82,85-88,102,109-114 Eight states (15.7%) prohibit smoking in the vehicles of FCCHs while transporting children.24,46,78,83,86,88,107,108 Eleven states (21.6%) require the provider to disclose their smoking habit to parents even if it is prohibited during hours of operation.21,33,50,52,55,76,80,102,109,110,112
| |
DISCUSSION |
|---|
|
Top
Abstract
Methods
Results
Discussion
References
|
|---|
In our review of child care regulations, we found that many states do not require child care providers to adopt basic precautions. Only 11.7% and 3.9% of states mandate the back or side position for infants under 6 months of age while sleeping in licensed CCCs and FCCHs, respectively. Crib safety is addressed by approximately one half of the states, with 63% of states requiring CCCs and 43.1% of states requiring at least 1 of the CPSC standards. Despite AAP11 and CPSC103 recommendations to avoid soft surfaces (blankets, pillows, and/or toys) in the crib, this safety standard is seldom stipulated, with only 11.7% and 7.8% of states requiring this of CCCs and FCCHs, respectively. It is alarming that basic safety requirements are not mandated, particularly in light of the high proportion of SIDS occurring in the care of a child care provider.1 We would suggest that state-licensing agencies incorporate safe crib standards and avoidance of soft bedding into regulations. In addition, regulations should stipulate that infants be placed supine for sleep unless a physician waiver is obtained.
Nearly one quarter of US states do not require infants to be cared for in a smoke-free environment. It is well established that exposure to secondhand smoke is an important risk factor, both for SIDS12,13 and for pediatric respiratory disease.115 Although infants attending child care are significantly more likely to come from nonsmoking homes,1 the protective effect of a smoke-free home is likely to be at least partly negated if the child spends daytime hours in a child care environment that is not smoke-free. State-licensing agencies must be encouraged to adopt basic safety standards regarding smoke exposure.
One third of states continue to use regulations written before the initial AAP policy statement in 1992.2 Many of the more recently adopted regulations still do not adequately address sleep safety for infants despite new data regarding sleep environment.
It is interesting to note that many state regulations are not consistent for both CCCs and FCCHs. Although the FCCH is a more informal setting than is a CCC and should not necessarily be held to the same requirements, basic safety must be addressed to the same degree in both settings.
The limitations of this study are linked to the data itself. We reviewed both state documents and information available through the Children's Foundation.15,16 All documents were reviewed by 2 of the investigators, and if a regulation was mentioned in any of the 3 sources, it was included in our tally. We did not solicit information regarding regulation for specific hazards from regulatory officials. In addition, we acknowledge that regulations may have been revised since our review or that states may be in the process of drafting new regulations that will be in effect in the near future.
Multiple studies have documented declines in both prone sleeping and SIDS deaths since the BTS campaign was launched in 1994.3,116,117 However, child care settings lag behind the home setting in avoidance of prone sleeping and other risk factors for SIDS.4,5 In 1999, all licensed CCCs in Maryland and the District of Columbia were sent mailings from BTS regarding the importance of safe sleep environment. In addition, there was much local media attention surrounding the deaths of 2 infants in a local FCCH.118,119 A survey conducted 6 months after the BTS mailing revealed that 27.9% of CCCs continued to place infants prone at least some of the time.5 Although information obtained through the media and BTS mailings often resulted in a change in child care policy, many centers were still unaware of the association between sleep environments and SIDS. This suggests that mailings and media exposure, although extremely effective, may not reach all targeted parties. Updated regulations of child care settings may be helpful in increasing adherence with safe sleep recommendations. We acknowledge, however, that the presence of regulations or national health safety standards does not ensure compliance by individual child care facilities.120 In a recent CPSC survey of child care settings, 8% had cribs that did not meet safety standards and 19% had cribs that contained soft bedding.120 We also acknowledge that the presence of state regulations does not ensure a lower incidence of SIDS. However, the presence of regulations may make it more likely that child care providers will implement a safe sleep policy,5 and implementation of the policy will reduce the risk of SIDS. Regulations can also act as a venue for the education of child care providers and parents. If a regulation is enacted, written information sent to child care providers can inform them of the reasons behind a policy and the safety risks if not followed.
Although the BTS campaign has been extremely successful in providing information about SIDS risk reduction, it has not reached all child care providers. It is critical that all persons caring for young infants become familiar with the components of a safe sleep environment. Furthermore, it is important for pediatricians to become proactive in promoting necessary safety regulations for child care settings in their states. Adoption of new regulations can aid in education of child care providers and, thus, improve the safety for the millions of children in child care.
| |
FOOTNOTES |
|---|
Received for publication Sep 5, 2000; accepted Sep 5, 2000.
Reprint requests to (R.Y.M.) Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, 111 Michigan Ave, NW Washington, DC 20010. E-mail: rmoon{at}cnmc.org
| |
ABBREVIATIONS |
|---|
SIDS, sudden infant death syndrome; AAP, American Academy of Pediatrics; BTS, Back to Sleep; CCC, child care center; FCCH, family child care home; CPSC, Consumer Product Safety Commission.
| |
REFERENCES |
|---|
|
Top
Abstract
Methods
Results
Discussion
References
|
|---|
1997.
Pediatrics
1998;
102:1333-1349 Current Population Reports. Washington, DC: US Census
Bureau; 1997This article has been cited by other articles:
 |
|
 |
|
  G. E. Matt, J. T. Bernert, and M. F. Hovell Measuring Secondhand Smoke Exposure in Children: An Ecological Measurement Approach J. Pediatr. Psychol., March 1, 2008; 33(2): 156 - 175. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Y. Moon, L. Kotch, and L. Aird State Child Care Regulations Regarding Infant Sleep Environment Since the Healthy Child Care America-Back to Sleep Campaign Pediatrics, July 1, 2006; 118(1): 73 - 83. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Task Force on Sudden Infant Death Syndrome The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk Pediatrics, November 1, 2005; 116(5): 1245 - 1255. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Y. Moon, B. M. Sprague, and K. M. Patel Stable Prevalence but Changing Risk Factors for Sudden Infant Death Syndrome in Child Care Settings in 2001 Pediatrics, October 1, 2005; 116(4): 972 - 977. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G A de Jonge, C I Lanting, R Brand, J H Ruys, B A Semmekrot, and J P van Wouwe Sudden infant death syndrome in child care settings in the Netherlands Arch. Dis. Child., May 1, 2004; 89(5): 427 - 430. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Y. Moon and R. P. Oden Back to Sleep: Can We Influence Child Care Providers? Pediatrics, October 1, 2003; 112(4): 878 - 882. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. M. Tomashek, J. Hsia, and S. Iyasu Trends in Postneonatal Mortality Attributable to Injury, United States, 1988-1998 Pediatrics, May 1, 2003; 111(5): 1219 - 1225. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Y. Moon, D. E. Weese-Mayer, and J. M. Silvestri Nighttime Child Care: Inadequate Sudden Infant Death Syndrome Risk Factor Knowledge, Practice, and Policies Pediatrics, April 1, 2003; 111(4): 795 - 799. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
||
|
||
Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2001 American Academy of Pediatrics. All rights reserved. |
||
|
||
