PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1029-1036

Examination of State Regulations Regarding Infants and Sleep in Licensed Child Care Centers and Family Child Care Settings

Rachel Y. Moon, MD^*, , Wendy M. Biliter, MD^*, , and Sarah E. Croskell, MD, MPH^§

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.

	METHODS

Top Abstract Methods Results Discussion References

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.

	RESULTS

Top Abstract Methods Results Discussion References

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

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 FCCHs^{25,26,50,54,55,75,76,79,80,82,84-86,93,94} 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 specifications^{17,30,36,37,90,91,95-99} 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 SIDS^12,13 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

1. Moon RY, Patel KM, Shaefer SJM Sudden infant death syndrome (SIDS) in child care settings. Pediatrics 2000; 106:295-300 [Abstract/Free Full Text]
2. American Academy of Pediatrics, Task Force on Infant Positioning and SIDS Positioning and SIDS. Pediatrics 1992; 89:1120-1126 [Abstract/Free Full Text]
3. Guyer B, MacDorman MF, Martin JA, Peters KD, Strobino DM Annual summary of vital statistics1997. Pediatrics 1998; 102:1333-1349 [Abstract/Free Full Text]
4. Gershon NB, Moon RY Infant sleep position in licensed child care centers. Pediatrics 1997; 100:75-78 [Abstract/Free Full Text]
5. Moon RY, Biliter WM Infant sleep position policies in licensed child care centers after Back to Sleep campaign. Pediatrics 2000; 106:576-580 [Abstract/Free Full Text]
6. US Bureau of the Census. Statistical Abstract of the United States: 1997. 117th ed. Washington, DC: US Bureau of the Census; 1997
7. Casper LM, O'Connell M. State Estimates of Organized Child Care Facilities. Washington, DC: US Bureau of the Census; 1998
8. Casper LM. Who's Minding Our Preschoolers?: Fall 1994, UpdateCurrent Population Reports. Washington, DC: US Census Bureau; 1997
9. American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care. Health in Day Care: A Manual for Health Professionals. Elk Grove Village, IL: American Academy of Pediatrics; 1987
10. Hofferth SL, Brayfield A, Deich S, Holcomb P. National Child Care Survey, 1990: A National Association for the Education of Young Children (NAEYC) Study. Washington, DC: Urban Institute; 1991
11. American Academy of Pediatrics, Task Force on Infant Positioning and SIDS Positioning and sudden infant death syndrome (SIDS): update. Pediatrics 1996; 98:1216-1218 [Abstract/Free Full Text]
12. Klonoff-Cohen HS, Edelstein SL, Lefkowitz ES, The effect of passive smoking and tobacco exposure through breast milk on sudden infant death syndrome. JAMA 1995; 273:795-798 [Abstract/Free Full Text]
13. Blair PS, Fleming PJ, Bensley D, Smoking and the sudden infant death syndrome: results from 1993-1995 case-control study for confidential inquiry into stillbirths and deaths in infancy. Br Med J 1996; 313:195-198 [Abstract/Free Full Text]
14. American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics 2000; 105:650-656 [Abstract/Free Full Text]
15. The Children's Foundation. 1999 Child Care Center Licensing Study. Washington, DC: The Children's Foundation, National Child Care Advocacy Program; 1999
16. The Children's Foundation. 1999 Family Child Care Licensing Study. Washington, DC: The Children's Foundation, National Child Care Advocacy Program; 1998
17. District of Columbia Service Facility and Regulation Administration. DCMR 29 Public Welfare Chapter 3 Child Development Facilities. Washington, DC: District of Columbia Service Facility and Regulation Administration; 1987
18. Wyoming Department of Family Services. Minimum Rules for Day Care Licensing. Cheyenne, WY: Wyoming Department of Family Services; 1990
19. Alaska Department of Health and Social Services, Division of Family and Youth Services, Chapter 50. Community Care Licensing: Child Care Facilities. Anchorage, AK: Alaska Department of Health and Social Services; 1998
20. New Hampshire Bureau of Child Care Licensing. New Hampshire: Child Day Care Agency Licensing Rules. Concord, NH: New Hampshire Bureau of Child Care Licensing; 1998
21. Nevada Bureau of Services for Child Care. Services for Facilities for Care of Children NAC-432A. Carson City, NV: Nevada Bureau of Services for Child Care; 1998
22. Mississippi State Department of Health, Division of Child Care. Regulations Governing Licensure of Child Care Facilities. Jackson, MS: Mississippi State Department of Health; 1998.
23. North Carolina Division of Child Development, Chapter 110 of the North Carolina General Statues, Subchapter 3U. Child Day Care Rules. Raleigh, NC: North Carolina Division of Child Development; 1999
24. New Mexico Children and Family Division, Child Care Services Bureau, Chapter 16. Child Care Licensing. Santa Fe, NM: New Mexico Children and Family Division; 1999
25. Minnesota Department of Human Services, Division of Licensing, Chapter 9502. Licensing of Day Care Facilities. Minneapolis, MN: Minnesota Department of Human Services; 1985
26. Alabama Department of Human Resources, Office of Day Care. Alabama's Minimum Standards for Family Day Care Homes and Family Nighttime Homes. Montgomery, AL: Alabama Department of Human Resources; 1988
27. Alabama Department of Human Resources, Office of Day Care. Alabama's Minimum Standards for Day Care Centers and Nighttime Centers. Montgomery, AL: Alabama Department of Human Resources; 1988
28. Delaware Office of Child Care Licensing, Delacare. Requirements for Day Care Centers. Wilmington, DE: Delaware Office of Child Care Licensing; 1988
29. Hawaii Department of Human Services, Benefit, Employment and Support Services Division, Employment/Child Care Program Office, Hawaii. Rules Governing Registration of Family Child Care Homes. Honolulu, HI: Hawaii Department of Human Services; 1988
30. Idaho Department of Health and Welfare, Bureau of Family and Children Services, Idaho. Day Care Center Standards. Boise, ID: Idaho Department of Health and Welfare; 1988
31. Indiana Family and Social Services Administration, Division of Family and Children, Indiana. Title 410: Indiana State Board of Health: Rule 2, Registered Day Care Ministries. Indianapolis, IN: Indiana Family and Social Services Administration; 1988
32. Kansas Department of Health and Environment, Bureau of Consumer Health, Child Care Licensing and Registration Section, Kansas. Regulations for Licensing Preschools and Child Care Centers. Topeka, KS: Kansas Department of Health and Environment; 1990
33. Kansas Department of Health and Environment, Bureau of Consumer Health, Child Care Licensing and Registration Section, Kansas. Regulations for Licensing Day Care Homes and Group Day Care Homes. Topeka, KS: Kansas Department of Health and Environment; 1990
34. Rhode Island Department of Children, Youth, and Families, Day Care Licensing, Rhode Island. Family Day Care Homes Regulations for Certification. Providence, RI: Rhode Island Department of Children, Youth, and Families; 1990
35. Texas Department of Protective and Regulatory Services. Minimum Standards for Registered Family Homes. Austin, TX: Texas Department of Protective and Regulatory Services; 1990
36. Georgia Child Care Licensing. Rules and Regulations for Day Care Centers. Atlanta, GA: Georgia Child Care Licensing; 1991
37. Hawaii Department of Human Services, Benefit, Employment and Support Services Division, Employment/Child Care Program Office, Hawaii. Licensing of Infant and Toddler Child Care Centers. Honolulu, HI: Hawaii Department of Human Services; 1991
38. Michigan Division of Child Day Care Licensing. Licensing Rules for Child Care Centers 1991-1992. Lansing, MI: Michigan Division of Child Day Care Licensing; 1992
39. Tennessee Department of Human Services. Licensure Requirements for Child Care Centers. Nashville, TN: Tennessee Department of Human Services; 1992
40. Louisiana Department of Social Services, Bureau of Licensing, Louisiana. Child Day Care Center: Class B Minimum Standards. Baton Rouge, LA: Louisiana Department of Social Services; 1992
41. Iowa Department of Human Services, Child Care Unit, Chapter 237A. Child Day Care Facilities. Des Moines, IA: Iowa Department of Human Services; 1999
42. Utah Bureau of Licensing, Child Care Unit. R430-100 Child Care Centers. Salt Lake City, UT: Utah Bureau of Licensing; 2000
43. State of New Jersey Department of Human Services, Division of Youth and Family Services, Bureau of Licensing, Chapter 122. Manual of Requirements for Child Care Centers. Trenton, NJ: State of New Jersey Department of Human Services; 1998
44. State of Illinois, Department of Children and Family Services. Part 407: Licensing Standards for Day Care Centers. Springfield, IL: State of Illinois, Department of Children and Family Services; 1998
45. Virginia Department of Social Services, Division of Licensing Programs. Virginia's Minimum Standards for Licensed Child Day Centers. Richmond, VA: Virginia Department of Social Services; 1998
46. Utah Bureau of Licensing, Child Care Unit, R430-90. Licensed Family Child Care. Salt Lake City, Utah Bureau of Licensing; 2000
47. Pennsylvania Office of Children, Youth, and Families, Chapter 3270. Child Day Care Centers. Harrisburg, PA: Pennsylvania Office of Children, Youth, and Families; 1998
48. Vermont Child Care Services Division. Children's Day Care Licensing Regulations for Early Childhood Programs. Waterbury, VT: Vermont Child Care Services Division; 1996
49. Montana Department of Public Health and Health Services. Montana's Supplemental Regulations for Infant Day Care. Helena, MT: Montana Department of Public Health and Health Services; 1995
50. Massachusetts Department of Public Health. Standards for Licensure or Approval of Family Child Care and Large Family Child Care Homes. Boston, MA: Massachusetts Department of Public Health; 1997
51. Vermont Child Care Services Division. Regulations for Family Day Care Homes. Waterbury, VT: Vermont Child Care Services Division; 1996
52. Pennsylvania Office of Children, Youth, and Families. Chapter 3290 Family Child Day Care Homes. Harrisburg, PA: Pennsylvania Office of Children, Youth, and Families; 1998
53. Montana Department of Public Health and Health Services. Requirements for Registration of Family Day Care Homes. Helena, MT: Montana Department of Public Health and Health Services; 1995
54. Oklahoma Department of Human Services, Office of Child Day Care. Oklahoma's Licensing Requirements for Family Day Care Homes. Oklahoma City, OK: Oklahoma Department of Human Services; 1994
55. Tennessee Department of Human Services. Standards for Family Day Care Homes. Nashville, TN: Tennessee Department of Human Services; 1994
56. Ohio Department of Human Services, Child Care Licensing Section, Ohio Department of Human Services. Type B Family Day Care Home Licensing Rules. Columbus, OH: Ohio Department of Human Services; 1996
57. US Consumer Product Safety Commission. CPSC Document 200: Tips for Your Baby's Safety: Nursery Equipment Safety Checklist. Washington, DC: US Consumer Product Safety Commission
58. Arizona Office of Child Care Licensure, Chapter 5. Child Care Facilities Rules. Phoenix, AZ: Arizona Office of Child Care Licensure; 1997
59. Arkansas Division of Child Care and Early Childhood Education. Minimum License Requirements for Child Care Centers. Little Rock, AR: Arkansas Division of Child Care and Early Childhood Education; 1998
60. California Department of Social Services, Office of Regulations Development, Child Care Center, Title 22, Divisions 12, Chapter 1; 1998
61. Maine Department of Human Services, Division of Licensing, Child Care Licensing Unit. Maine Rules for the Licensing of Children's Day Care Facilities Chapter 32. Augusta, ME: Maine Department of Human Services; 1998
62. Minnesota Department of Human Services, Division of Licensing, Chapter 9503. Licensing Requirements for Child Care Centers. Minneapolis, MN: Minnesota Department of Human Services; 1994
63. Missouri Department of Health, Bureau of Child Care Safety and Licensure. Licensing Rules for Group Child Care Homes and Child Care Centers. Jefferson City, MO: Missouri Department of Health; 1996
64. Montana Department of Public Health and Health Services. Licensing Requirements for Child Day Care Centers. Helena, MT: Montana Department of Public Health and Health Services; 1995
65. Ohio Department of Human Services, Child Care Licensing Section. Ohio Department of Human Services Child Day Care Center Licensing Rules. Columbus, OH: Ohio Department of Human Services; 1995
66. Oklahoma Department of Human Services, Office of Child Care. Oklahoma's Licensing Requirements for Child Care Centers. Oklahoma City, OK: Oklahoma Department of Human Services; 1999
67. Oregon Child Care Division. Rules for Certification of Child Day Care Centers. Salem, OR: Oregon Child Care Division; 1996
68. South Carolina Department of Social Services, Division of Child Day Care Licensing and Regulatory Services. South Carolina's Regulations for Child Day Care Centers. Columbia, SC: South Carolina Department of Social Services; 1993
69. Washington Department of Social and Health Services, Office of Child Care Policy. Minimum Licensing Requirements for Child Day Care Centers. Olympia, WA: Washington Department of Social and Health Services; 1997
70. West Virginia Social Services, Emergency Rule Title 64 West Virginia Legislative Rule, Division of Health, Series 21, Child Care Centers; 1997.
71. Colorado Department of Social Services, Division of Child Care. Colorado's Rules Regulating Child Care Centers. Denver, CO: Colorado Department of Social Services; 1995
72. Nebraska Health and Human Services, System Regulation and Licensure. Child Care Center Standards. Lincoln, NE: Nebraska Health and Human Services; 1998
73. North Dakota Department of Human Services, North Dakota Child Care Center Early Childhood Services, Chapter 75-03-10, Child Care Centers; 1999
74. Maryland Office of Licensing, Child Care Administration. Code of Maryland Regulations 07.04.02 Child Care Center Licensing. Baltimore, MD: Maryland Office of Licensing; 1998
75. Arizona Department of Economic Security, Child Care Administration. Article 52 Certification and Supervision of Family Child Care Home Providers. Phoenix, AZ: Arizona Department of Economic Security; 1999
76. Arkansas Division of Child Care and Early Childhood Education. Minimum Standards Required for Licensing of Day Care Family Homes. Little Rock, AR: Arkansas Division of Child Care and Early Childhood Education; 1998
77. Georgia Child Care Licensing. Rules and Regulations for Family Day Care Homes. Atlanta, GA: Georgia Child Care Licensing; 1994
78. State of Illinois, Department of Children and Family Services. Part 406: Licensing Standards for Day Care Homes. Springfield, IL: State of Illinois, Department of Children and Family Services; 1997
79. Missouri Department of Health, Bureau of Child Care Safety and Licensure. Licensing Rules for Family Child Care Homes. Jefferson City, MO: Missouri Department of Health; 1997
80. State of New Jersey Department of Human Services, Division of Youth and Family Services, Bureau of Licensing. Manual of Requirements for Family Day Care Registration. Trenton, NJ: State of New Jersey Department of Human Services; 1998
81. Ohio Department of Human Services, Child Care Licensing Section. Ohio Department of Human Services Type A Family Day Care Home Licensing Rules. Columbus, OH: Ohio Department of Human Services; 1995
82. Oregon Child Care Division. Family Child Care Registration Without Inspection. Salem, OR: Oregon Child Care Division; 1999
83. Washington Department of Social and Health Services, Office of Child Care Policy. Minimum Licensing Requirements for Child Day Care Homes. Seattle, WA: Washington Department of Social and Health Services; 1997
84. South Carolina Department of Social Services, Division of Child Day Care Licensing and Regulatory Services. South Carolina's Regulations for Family Day Care Homes: 114-528 Definitions and Procedures. Columbia, SC: South Carolina Department of Social Services; 1993
85. Virginia Department of Social Services, Division of Licensing Programs. Virginia's Minimum Standards for Licensed Family Day Homes. Richmond, VA: Virginia Department of Social Services; 1993
86. West Virginia Social Services, Title 78 Emergency Legislative Rule, Division of Human Services. Series 18 Family Day Care Facility Certification Requirements. Clarksburg, WV: West Virginia Social Services; 1997
87. North Dakota Department of Human Services, North Dakota Family Child Care Early Childhood Services, Chapter 75-03-08; 1999
88. New York Department of Social Services, Part 417. Family Day Care Homes. Albany, NY: New York Department of Social Services; 1996
89. Louisiana Department of Social Services, Bureau of Licensing. Child Day Care Center Class A Minimum Standards. Baton Rouge, LA: Louisiana Department of Social Services; 1999
90. State of Connecticut Department of Public Health. Day Care Center and Group Day Care Home Licensing Statutes and Regulations. Hartford, CT: State of Connecticut Department of Public Health; 1998
91. New York Department of Social Services, Part 418. Day Care Centers. Albany, NY: New York Department of Social Services; 1996
92. Wisconsin Bureau of Regulation and Licensing, HFS 46. Licensing Rules for Group Day Care Centers. Madison, WI: Wisconsin Bureau of Regulation and Licensing; 1998
93. Maine Department of Human Services, Division of Licensing, Child Care Licensing Unit. Maine Rules for Home Day Care Providers Chapter 33. Augusta, ME: Maine Department of Human Services; 1998
94. Michigan Division of Child Day Care Licensing. Licensing Rules for Family and Group Day Care Homes (12/94). Lansing, MI: Michigan Division of Child Day Care Licensing; 1994
95. Florida Department of Children and Families, Family Safety and Preservation/Child Care. Rules of the Department of Health and Rehabilitatives, Chapter 65C-22: Child Care Standards. Tallahassee, FL: Florida Department of Children and Families; 1999
96. Kentucky Department of Community Based Services, Division of Child Care. 905 KAR 2.001-2:120 Standards for All Child Care Facilities. Frankfort, KY: Kentucky Department of Community Based Services; 1994
97. Massachusetts Department of Public Health. Standards for Licensure or Approval of Group Day Care and School Age Child Care Programs. Boston, MA: Massachusetts Department of Public Health; 1997
98. State of South Dakota, Child Care Services. South Dakota's Day Care Centers: Chapter 67.42:10. Pierre, SD: State of South Dakota; 1998
99. State of South Dakota, Child Care Services. South Dakota's Environmental Health Standards: Chapter 67.42:11. Pierre, SD: State of South Dakota; 1998
100. Rhode Island Department of Children, Youth and Families, Day Care Licensing. Child Day Care Center Regulations for Licensure. Providence, RI: Rhode Island Department of Children; 1993
101. Texas Department of Protective and Regulatory Services. Day Care Centers Minimum Standards and Guidelines. Austin, TX: Texas Department of Protective and Regulatory Services; 1997
102. Nebraska Health and Human Services, System Regulation and Licensure. Family Child Care Home Standards. Lincoln, NE: Nebraska Health and Human Services; 1998
103. US Consumer Product Safety Commission. Recommendations Revised to Prevent Infant Deaths From Soft Bedding. Washington, DC: Consumer Product Safety Commission; 1999
104. Kemp JS, Livne M, White DK, Arfken CL Softness and potential to cause rebreathing: differences in bedding used by infants at high and low risk for sudden infant death syndrome. J Pediatr 1998; 132:234-239 [CrossRef][Medline]
105. Scheers NJ, Dayton CM, Kemp JS Sudden infant death with external airways covered: case-comparison study of 206 deaths in the United States. Arch Pediatr Adolesc Med 1998; 152:540-547 [Abstract/Free Full Text]
106. California Department of Social Services, Office of Regulations Development, Family Child Care Homes, Title 22, Division 12, Chapter 3; 1997
107. Colorado Department of Social Services, Division of Child Care. Colorado's Rules Regulating Family Child Care Homes. Denver, CO: Colorado Department of Social Services; 1995
108. Wisconsin Bureau of Regulation and Licensing, HFS 45. Licensing Rules for Family Day Care Centers for Children. Madison, WI: Wisconsin Bureau of Regulation and Licensing; 1998
109. State of Connecticut Department of Public Health. Family Day Care Home Licensing Statutes and Regulations. Hartford, CT: State of Connecticut Department of Public Health; 1997
110. Florida Department of Children and Families, Family Safety and Preservation/Child Care. Rules of the Department of Health and Rehabilitatives Chapter 65C-20: Family Day Care Standards. Tallahassee, FL: Florida Department of Children and Families; 1998
111. Kentucky Department of Community-Based Services, Division of Child Care. 905 KAR 2.100 Certification of Family Child-Care Homes. Frankfort, KY: Kentucky Department of Community-Based Services; 1998
112. Maryland Office of Licensing, Child Care Administration. Code of Maryland Regulations 07.04.01 Family Day Care. Baltimore, MD: Maryland Office of Licensing; 1999
113. State of South Dakota, Child Care Services. Family Day Care Homes: Chapter 67. 42:03. Pierre, SD: State of South Dakota; 1998
114. Iowa Department of Human Services, Child Care Unit, Chapter 110. Family and Group Day Care Homes. Des Moines, IA: Iowa Department of Human Services; 1999
115. Arshad S, Hide D Effect of environmental factors on the development of allergic disorders in infancy. J Allergy Clin Immunol 1992; 90:235-241 [CrossRef][Medline]
116. Willinger M, Hoffman HJ, Wu K-T, Factors associated with the transition to nonprone sleep positions of infants in the United States: the National Infant Sleep Position Study. JAMA 1998; 280:329-335 [Abstract/Free Full Text]
117. Centers for Disease Control and Prevention. Guidelines for death scene investigation of sudden, unexplained infant deaths: recommendations of the interagency panel on sudden infant death syndrome. MMWR CDC Surveill Summ. 1996;45(RR-10)
118. St George D. Deaths put spotlight on home day care. The Washington Post. December 6, 1998:A1
119. St George D. On SIDS, parents ahead of caregivers. The Washington Post. December 15, 1998:A2
120. Consumer Product Safety Commission. CPSC Staff Study of Safety Hazards in Child Care Settings. Washington, DC: Consumer Product Safety Commission; 1999
121. Indiana Family and Social Services Administration, Division of Family and Children. Regulations for Licensing Day Nurseries (470 IAC 3-4.1). Indianapolis, IN: Indiana Family and Social Services Administration; 1985
122. Delaware Office of Child Care Licensing, Delacare. Requirements for Family Child Care Homes. Wilmington, DE: Delaware Office of Child Care Licensing; 1994
123. Delaware Office of Child Care Licensing, Delacare. Requirements for Large Family Child Care Homes. Wilmington, DE: Delaware Office of Child Care Licensing; 1994
124. Indiana Family and Social Services Administration, Division of Family and Children. Title 470 Division of Family and Children: Rule 1.1 Child Care Homes. Indianapolis, IN: Indiana Family and Social Services Administration; 1996
125. Indiana Family and Social Services Administration, Division of Family and Children. Title 470 Division of Family and Children: Rule 1.3 Class II Child Care Homes. Indianapolis, IN: Indiana Family and Social Services Administration; 1996