Back to Sleep: Can We Influence Child Care Providers?
* Department of General Pediatrics, Children’s National Medical Center, Washington, DC
Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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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.
Key Words: sudden infant death syndrome • risk reduction • intervention • child care • sleep position
Abbreviations: SIDS, sudden infant death syndrome • SD, standard deviation • AAP, American Academy of Pediatrics • BTS, Back to Sleep
Two thirds of US infants under the age of 12 months are in nonparental child care.1 Infants of employed mothers spend an average of 22 hours each week in child care, and 32% of infants are in child care full time. Approximately half of the infants in nonparental child care arrangements are in organized child care, ie, a child care center or family child care home.1
In the United States, approximately 20% of sudden infant death syndrome (SIDS) deaths occur while the infant is in the care of a child care provider.2 Despite the remarkable decline in SIDS from 1.2 SIDS deaths per 1000 live births in 1992 to 0.53 per 1000 live births in 20003 and the decreased frequency of prone sleeping from 70% in 1992 to 17% in 1998,4 the proportion of SIDS deaths that occur in child care has remained constant.2 Many of the child care deaths are associated with the prone sleep position, especially when the infant is unaccustomed to being placed in that position.2 This is particularly concerning, as it has been well established that unaccustomed prone sleep increases the risk of SIDS 18-fold.5,6
However, many child care providers continue to place infants prone. A 1996 study revealed that 43% of licensed child care centers were unaware of the association of SIDS and infant sleep position,7 and subsequent surveys of child care centers have documented that despite an increased awareness, 20% to 25% of centers continue to place infants prone for sleep.8,9 The primary reasons that child care providers place infants prone are that they are unaware of the dangers of sleeping prone and/or are misinformed as to the risks and benefits of the various sleep positions.7–9 Providers are more likely to report using the supine position when centers have written sleep policies.7–9 However, licensed child care centers seldom have adequate regulations regarding safe sleep for infants.10
To that end, we have developed an educational program for child care providers regarding SIDS and safe sleep environment for infants. The objectives of the program are 1) to provide basic information and understanding regarding SIDS risk reduction practices, 2) to change child care provider behavior regarding infant sleep position, and 3) to encourage development of written sleep policies.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We designed a 60-minute educational in-service for child care providers. The in-service was offered to child care providers through a collaboration with the Office of Early Childhood Development, Department of Human Services, Washington, DC (the licensing agency for child care providers), which requires annual training for continued licensure. SIDS training is not required for licensure, and the District of Columbia does not currently mandate nonprone sleeping in child care settings.11 A trained health educator led all of the educational sessions and discussed the components of safe sleep environment for infants, statistics linking sleep position and SIDS, and common misconceptions and concerns about the supine position. All child care providers were asked to complete surveys before and after the in-service. Surveys assessed provider knowledge, beliefs, and practices. Providers were also asked about the presence of a written policy in their child care center regarding sleep position. We did not receive copies of the written policies.
Six months later, we interviewed child care centers that had providers participating in the in-service. A research assistant, who identified herself as an employee of Children’s National Medical Center, conducted the interview. The purpose of the follow-up interview was to determine whether center sleep practice and policy reflected information that the providers had received during the in-service. The follow-up interview was with the child care center director or a supervisor who was familiar with the care of infants and not necessarily with a provider who had attended the in-service. Statistical analysis, including 
2, was performed.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Child Care Provider Demographics
A total of 96 child care providers, representing 23 centers and 31 family child care homes, participated in sessions from August 2000 through October 2001. Approximately half were providers in child care centers; the other half were family child care providers. Participants had a mean age of 40.8 years (17–73; standard deviation [SD]: 13.04) and had been caring for children for an average of 9.1 years (1 month–34 years; median: 7.0 years; SD: 8.03). They cared for an average of 32.3 (1–150; median: 15.0; SD: 39.2) children and 1.7 (0–22; SD: 3.3) infants. Approximately half of the centers (12 centers and 15 family child care homes) were available for 6-month follow-up interview. The other centers were not included in the follow-up interview because they did not care for infants (6 centers, 11 family child care homes), declined participation (2 centers, 2 family child care homes), or could not be reached (3 centers, 3 family child care homes).
Before Intervention
Knowledge of SIDS Risk Factors
When child care providers were asked whether they believe that sleeping prone increases the risk for SIDS in healthy infants, one third (31.3%) stated that there is a definite risk to sleeping prone. An additional 19.8% believed that there is possibly a risk, 35.4% were unsure, and 13.6% did not believe that prone increases the risk of SIDS.
Nearly half (46 [47.9%]) of the providers were aware that the American Academy of Pediatrics (AAP) recommends the supine position for healthy sleeping infants; an additional 24% believed that the recommendation is side or back. Nearly one fourth (21.9%) did not know what the recommendation is. Only one third (31.3%) had heard of the Back to Sleep (BTS) campaign (Table 1).
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Sleep Position Practice and Rationale
When child care providers were asked about usual sleep position for infants, 43 (44.8%) responded that they usually placed infants supine, 14 (14.6%) side, and 3 (3.1%) prone. An additional 36 (38%) stated that they did not use a consistent sleep position for infants but placed them in any position, including prone, based on parent or provider preference.
Reasons for infant positioning varied, and 38 (39.6%) providers cited >1 reason motivating their choice of infant sleep position (Table 2). The most commonly cited reasons included SIDS risk reduction or safety reasons (54.2%), fear of suffocation (38.5%), and fear of choking (31.3%). The most common combinations of reasons were SIDS risk reduction and fear of suffocation (24 [25%]), fear of choking and fear of suffocation (23 [24.0%]), and SIDS risk reduction and fear of choking (19 [19.8%]).
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Of the 43 providers who usually place infants supine, the vast majority (37 [86.0%]) did so because of SIDS risk reduction or safety reasons. In fact, when SIDS/safety was cited as a reason for positioning, the provider was more likely to place infants exclusively supine (P < .0001). Providers were also more likely to place infants exclusively supine when there were more infants in the center (P = .04), when the provider believed that the prone position increased the risk of SIDS (P < .0001), when the provider knew that supine was recommended by the AAP (P < .0001), and when the center had a written policy regarding sleep position (P = .0002). When the provider cited infant comfort (ie, infant sleeps better) as a reason for infant position (P = .02) or could not give a reason (P < .0001), he or she was less likely to place infants exclusively supine.
Providers who used the side position (n = 14) most commonly cited SIDS risk reduction or safety (10 [71.4%]) fear of suffocation (8 [57.1%]), and fear of choking (8 [57.1%]) as reasons. Infants were more likely to be placed exclusively on the side when the provider cited choking (P = .004) or infant comfort (P = .04) as reasons. The majority (57.6%) of the 36 providers who did not use a consistent sleep position could not state a reason for their sleep position practice; most commonly cited reasons included fear of suffocation (28.6%), fear of choking (20%), and infant comfort (17.1%). Providers were more likely to place infants prone at least some of the time when they could not cite a reason for their practice (P < .0001) and when they had no knowledge about the AAP recommendations (P < .0001). The 3 providers who placed infants exclusively prone cited infant comfort, fear of choking, and fear of suffocation as reasons.
Written Policies
Before the intervention, 18 (18.8%) providers reported having written policies in their center. Providers in centers with written policies were more likely to designate SIDS as a reason for sleep positioning (P < .0001), to be aware of AAP recommendations (P = .008), and to work in centers that care for more infants (P = .001). Of the centers with written policies, 10 (55.6%) policies stipulated exclusive placement in supine, 2 allowed side or back, and 1 had a side-only policy. Five providers who indicated that their centers had written policies were unaware of the content of the policy.
Immediately After Intervention
Knowledge of SIDS Risk Factors
Immediately after the intervention, there was increased awareness of the AAP recommendation, with 75 (78.13%) recognizing supine as the preferred position (P = .004). An additional 15 providers (15.6%) believed the recommendation to be side or back. Although there was a near doubling of participants from 30 to 54 (56.3%) believing that prone position definitely increases the risk of SIDS, this was not statistically significant. An additional 14 (14.6%) believed that there is possibly a risk, and 28 remained unsure.
Sleep Position Practice
After the in-service, more than three fourths (75 [78.13%]) of the providers planned to place infants supine exclusively with the sole exception of physician or parental waiver, a significant change from initial reported practice (P = .04). An additional 10 planned to place infants on the side or back, 3 exclusively on the side, and 6 did not specify.
Long-Term Follow-up
Knowledge of SIDS Risk Factors
Two thirds (67.7%) of center directors/supervisors recognized supine as the position recommended by the AAP, a percentage similar to that found in child care providers immediately after the in-service. More than one fourth (29.6%) believed prone definitely to increase the risk of SIDS, and an additional one fourth (25.9%) believed prone likely to increase the risk of SIDS. These percentages represent a decline from immediately after the in-service and are similar to those seen preintervention.
Sleep Position Practice
Eighty-five percent of the centers were placing infants exclusively supine 6 months after the in-service, a higher percentage than was found immediately after the in-service. The vast majority of these (78%) did so to reduce the risk of SIDS. Nearly half (44.4%) of the centers had a written policy regarding safe sleep environment for infants, more than double the percentage reported before the in-service (P < .01) All written policies stipulated supine position except for 2, 1 of which prohibited blankets in the crib. The other policy stipulated that all infants sleep on the floor.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Behavior change with regard to safe sleep environment for infants has been more difficult to effect in child care providers than in parents since the BTS campaign was launched. Although the topic of SIDS and risk reduction has increasingly been covered in the media, the media outlets that have been used may not be ones to which child care providers typically are exposed. Furthermore, although targeted mailings from BTS have been effective in changing provider behavior,8 many providers have no recollection of receiving such mailings. Many child care providers continue to be unaware of the importance of supine positioning. Indeed, we found that, before the intervention, only half of the providers in our study population were aware that the AAP recommends the supine sleep position for healthy, term infants. Two thirds had never heard of BTS, and an equal number did not believe that prone increases the risk of SIDS. Even when people are made aware of the supine recommendation, it is often difficult to change the tradition and long-standing practice of placing infants prone for sleep, especially when the practice is accompanied by perceptions that placing infants in a position other than prone will increase the risk of choking or aspiration and that the prone position is the most comfortable for the infant. The primary reasons cited by providers in this survey for placing infants in the nonsupine position included fear of suffocation, fear of choking, and infant comfort.
We therefore developed an educational in-service targeted toward child care providers to raise awareness of the importance of placing infants in the supine position and to debunk myths and misconceptions regarding the risks and benefits of the various sleep positions. We found that this type of in-service had the immediate positive effects of changing providers’ planned behavior with regard to sleep position and increasing knowledge of AAP recommendations. Furthermore, these changes have been sustained for at least a 6-month period and have been accompanied by an increase in written sleep policies in child care centers. This last result is especially important, as it has been well established that child care providers are much more likely to place infants supine and practice other safe sleep behaviors when a written sleep policy is in effect in the center.8,9
Legal liability was not mentioned as a motivation for policy change by any of the providers who were interviewed. There has been a great deal of recent publicity surrounding cases of infants dying of SIDS while under the care of a child care provider, with subsequent legal action, either criminal or civil, being taken against the provider.12–14 It would not be surprising if child care providers consider the possibility of legal liability as an additional, unspoken reason for placing infants supine.
It is unfortunate that the in-service did not positively affect child care providers’ belief in the relationship of prone and SIDS. We did not see a significant increase in the number of providers who believed that prone definitely or possibly increases the likelihood of SIDS. There unfortunately continues to be a great deal of skepticism about the importance of placing infants supine; however, this is not unique to child care providers. Health care professionals have also been slow to change their sleep position practices and advice given to families,15–18 whether it be because of lack of knowledge, incorrect knowledge, or skepticism. It is possible that objective data linking sleep position with SIDS is not sufficient to change long-standing beliefs and that other, more subjective information, such as live or videotaped testimony of parents or child care providers who have lost an infant to SIDS, may be important in altering beliefs and in convincing providers that SIDS is more than an abstract concept.
One apparent limitation to the study is that we did not interview the same providers who attended the in-service in the 6-month follow-up. However, we believed that it was important to learn whether the information provided to the providers at the in-service would be disseminated to the child care center and result in improved knowledge and promote creation of written policy. We did not assess to what degree child care providers are checked to ensure that practices are in accordance with policy. In addition, we were unable to interview a control group of child care centers. Although it would have been desirable to compare the study centers’ practices with controls, we were unable to find a comparable control group, as the majority of centers who care for infants attended the in-service.
It is clear that targeted educational opportunities for child care providers are effective in increasing knowledge and awareness of SIDS risk factors, changing provider behavior, and promoting creation of written sleep position policies. It will be important to establish that the gains achieved through these types of interventions continue to be sustained through ongoing education and outreach from state and corporate licensing agencies.
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ACKNOWLEDGMENTS |
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This work was supported by a grant from the Gerber Foundation.
We thank Stormy Stringer, Office of Early Childhood Development, Department of Human Services, Washington, DC, for assistance in scheduling in-services and Joana Iglesias for assistance in data collection and database management.
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FOOTNOTES |
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Received for publication Oct 17, 2002; Accepted Feb 24, 2003.
Reprint requests to (R.Y.M.) Department of General Pediatrics, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: rmoon{at}cnmc.org
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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