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Stable Prevalence but Changing Risk Factors for Sudden Infant Death Syndrome in Child Care Settings in 2001

Rachel Y. Moon, MD^*,,, Bruce M. Sprague, BS and Kantilal M. Patel, PhD^,

^* Division of General Pediatrics and Community Health, Goldberg Center for Community Pediatric Health
Center for Health Services and Community Research, Children’s Research Institute, Children’s National Medical Center, Washington, DC
Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC

	ABSTRACT

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Objective. A total of 20% of sudden infant death syndrome (SIDS) cases in the 1990s occurred in child care settings. This is much higher than the 8% expected from Census Bureau data. Factors that were associated with child care SIDS included older age; white race; older, more educated mothers; and unaccustomed prone position. Since these findings, much emphasis has been placed on promoting a safe sleep environment in child care. The objectives of this study were to determine the proportion of SIDS occurring in child care in 2001 and to assess risk factors for SIDS in child care.

Methods. We conducted a retrospective review of all SIDS deaths that occurred in 2001 in 13 US states. Information regarding demographics, SIDS risk factors, and child care arrangements were collected and analyzed. Deaths that occurred in child care were compared with deaths that occurred during parental care.

Results. Of 480 deaths, 79 (16.5%) occurred in child care settings. Of these child care deaths, 36.7% occurred in family child care homes, 17.7% occurred in child care centers, 21.3% occurred in relative care, and 17.7% occurred with a nanny/babysitter at home. Infants in child care were more likely to be older and to die between the hours of 8 AM and 4 PM and less likely to be exposed to secondhand smoke. There was no difference in usual, found, or placed sleep position between child care and home deaths. Approximately one half of the infants who died of SIDS in both settings were found prone, and 20% of deaths in both settings were among infants who were unaccustomed to prone sleep.

Conclusions. The proportion of SIDS deaths in child care has declined slightly but still remains high at 16.5%. Infants in child care are no more likely to be placed or found prone and no more likely to be on an unsafe sleep surface. Educational efforts with child care providers have been effective and should be expanded to unregulated child care providers. In addition, there may be other, yet-unidentified factors in child care that place infants in those settings at higher risk for SIDS.

Key Words: sudden infant death syndrome • risk reduction • intervention • child care • sleep position

Abbreviations: SIDS, sudden infant death syndrome

Since 1992, when the American Academy of Pediatrics endorsed the nonprone sleep position for healthy infants,¹ the percentage of infants who are placed prone for sleep has decreased from 70% in 1992 to 12% in 2001.² Concurrently, the incidence of SIDS has declined 53% from 1992 to a rate of 0.56 per 1000 live births in 2001.³

More than half (55.2%) of women with infants (ie, children <1 year of age) were in the workforce in 2000, with 60% of these mothers working full time.⁴ Approximately 50%⁵ of infants are in regular, nonparental child care during the first year of life. Most infants start in nonparental child care before the age of 4 months⁶ and spend an average of 28 hours each week in child care.^5–7 Among infants in nonparental care, 23% are in center-based care, 20% are in family child care homes, 42% are in relative care, and 14% are in babysitter/nanny care (Table 1). ⁷

In our initial report,⁸ we found that demographic factors associated with SIDS in child care settings included older age, race (black infants were underrepresented), and highly educated parents. In addition, a child’s being unaccustomed to prone sleeping was highly associated with SIDS in child care. Since this report, the Back to Sleep campaign and individual states have placed an emphasis on promoting a safe sleep environment in child care. The Back to Sleep campaign sponsored a nationwide mailing of informational materials to all licensed child care providers in 2000, and many states began providing SIDS risk reduction training for child care providers. By 2001, 6 states mandated the nonprone sleep position for infants in licensed child care, and 6 prohibited soft bedding.¹¹ In addition, many child care centers developed written sleep position policies.^12,13 However, in 2001, approximately one fourth of child care centers continued to place infants prone.^12,13

In light of this increased emphasis on educating child care providers about the importance of the supine sleep position and a safe sleep environment for infants, it is worthwhile to reexamine both the prevalence of SIDS in child care settings and the factors related to these deaths. We hypothesized that the percentage of SIDS deaths that occur in child care is decreasing but that infant sleep position, particularly the unaccustomed prone position, continues to play a role in these deaths.

	METHODS

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We performed a retrospective surveillance study of all deaths that were attributed to SIDS from January through December 2001 in 13 geographically diverse states (California, Colorado, District of Columbia, Delaware, Idaho, Kansas, Louisiana, Massachusetts, Maryland, Michigan, North Dakota, New Mexico, and Pennsylvania). Data collection has been previously described.⁸ Data collected included birth history, demographic information, smoke exposure, sleep position (usual and last placed), position found, location of death, sleep environment (bedsharing, soft bedding), time of death, caregiver at time of death, prenatal exposures (alcohol, drugs, or tobacco), breastfeeding, medical problems, and recent changes in the child’s routine. Location of death was categorized as in a child care setting or not in a child care setting. Not in child care was defined as under the care of a parent or a guardian. These deaths usually occurred at home, but some occurred in cars, camper-trailers, or strollers. Child care settings were divided into at home with a babysitter or nanny (relative or nonrelative), in the care of a relative in the relative’s home, in a family child care home, or in a child care center (Table 1).^14–16

Frequencies of the demographic variables were tabulated. The outcome measure was location of death (dying of SIDS in a child care setting vs dying of SIDS in the care of the parent/guardian). We performed univariate and multiple logistic regression analyses to identify demographic variables and factors associated with the outcome measure. The institutional review board of Children’s National Medical Center approved this study.

	RESULTS

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Data were provided by the 13 participating states on a total of 533 SIDS cases, representing all of the SIDS deaths in those states between January and December 2001 (Table 2). Ten percent (53) of the cases were excluded because the location of death was not documented, resulting in a sample size of 480 cases. The excluded cases were similar to the cohort cases in gender, mean gestational age, and birth weight. The excluded cases were an average of 12.3 days younger and were more likely to be black (40.0% vs 29.9%).

Temporal Factors
In the 344 cases for whom the information was available, 49.7% died during the daytime hours of 8:00 AM to 3:59 PM, 11.3% from 4:00 PM to 11:59 PM, and 39.0% from midnight to 7:59 AM. The time of death was unknown for 28.8%. Approximately one third (35.8%) of deaths occurred in the winter months of December through February, with 21.9% occurring in the months of March to May, 17.5% in June to August, and 24.4% in September to November. More than three quarters (77.2%) of deaths occurred during weekdays, and 22.8% occurred on weekends. The temporal factors in the current survey were similar to those found in the previous survey.

Sleep Environment
In our sample, 29.4% of infants were found in cribs; 40.7% were found on adult beds; 11.9% were found on sofas; 7% were found on the floor (usually on a mattress or blanket); 3.7% were found in playpens; and 7.3% were found in other places, such as strollers, car seats, and infant carriers. In 44.6% of deaths, there was documentation of soft bedding. One third (32.9%) of infants were bedsharing, ie, sharing their sleeping surface with at least 1 other person, most frequently a parent. Half (49.8%) of infants were found in the prone position; 35.7% were found supine, and 14.5% were found on the side. Thirty percent had been placed prone, and for 39.8%, prone was the usual position. Unaccustomed prone position (when the infant is found or placed prone when prone is not the usual position) was documented in 20.2% of deaths. The rates of prone position and bedsharing in this survey were not significantly different from our previous survey.

Child Care Setting
In our sample, 79, or 16.5% of deaths occurred in various child care settings. Of the child care deaths, 17.7% occurred with a nanny/babysitter, 21.3% occurred in a relative’s home, and 54.4% occurred in organized child care settings (36.7% in family child care homes and 17.7% in child care centers). In 6 (7.6%) cases, the type of child care was not documented. Compared with the previous survey, a higher proportion of infants died while under the care of a nanny/babysitter (17.7% vs 6.4%; P < .001) and in child care centers (17.7% vs 12.7%; P < .01); the proportion in family child care homes decreased (36.7% vs 59.3%; P < .001), and the proportion in a relative’s home remained stable (21.3% vs 21.1%). The proportion of child care deaths in the individual states ranged from 0% (District of Columbia and Idaho) to 33.3% (Delaware and Kansas; Table 2).

The prevalence of prone as the position placed was not increased in the child care cohort. Among the infants in child care, 31.8% were placed prone, 47.7% were supine, and 20.5% were on the side, compared with 29.7% of those not in child care who were placed prone, 45.5% supine, and 24.8% on the side. Usual and found sleep position were similar in the 2 cohorts, as was the proportion of unaccustomed prone position. Approximately 20% (21.3% of deaths in child care; 20% of deaths not in child care) of each cohort were infants who were unaccustomed to prone sleep.

When we analyzed demographic characteristics and other factors in a multiple logistic regression model for association with location of death (Table 3), we found that, compared with SIDS that did not occur in child care, SIDS that occurred in child care was more likely to occur between the hours of 8 AM and 4 PM, and infants were more likely to be older at the time of death and less likely to be exposed to environmental tobacco smoke. Black infants were underrepresented in the group of infants in child care, but this was not statistically significant on multiple logistic regression. Parental age and educational status were similar in the 2 groups.

When we stratified the data by child care type, we found that, as was the case in our original survey, the demographic characteristics of infants who died in a relative’s home and those who died in the care of their parents/guardians were similar. The infants who died in the care of a parent, guardian, or relative were more likely to be younger (93.58 vs 135.9 days; P < .01), black (32.7% vs 10.11%; P < .001), and exposed to environmental tobacco smoke (64.6% vs 16.6%; P < .001) than those who died in the care of a nanny or while in organized child care. Maternal age was similar for infants in all types of child care. Maternal education for infants in relative care, child care centers, and family child care homes were similar and somewhat lower than that seen in infants with nannies, for whom 100% of the mothers had received postsecondary education.

	DISCUSSION

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The percentage of SIDS deaths that occur in child care has decreased since our original survey. Although the current percentage is still higher than would be anticipated by Census Bureau data, this may be somewhat of an overestimation because of a diagnostic shift that occurred during the years between the 2 surveys. Research has demonstrated the importance of external factors, such as soft bedding and sleeping face down, in causing deaths that were previously attributed to SIDS.^17–19 Medical examiners are now more likely to ascribe sudden unexpected infant deaths that occur on adult beds or while bedsharing to accidental asphyxia, suffocation, or undetermined.²⁰ These deaths, which are more likely to occur at home than in child care, would not have been included in this survey.

It is intriguing that sleep position no longer is a significant factor in child care SIDS deaths. Thirty percent of infants both in child care settings and at home were placed prone for sleep, and we found no association in this survey between unaccustomed prone position and child care. In addition, infants who die in child care are no more likely to be in an unsafe sleep environment. There was no significant difference with regard to bed sharing, soft bedding, and sleep surface on multiple logistic regression analysis. Infants in child care are also less likely to experience secondhand smoke exposure, which has been shown in multiple studies to be an important risk factor for SIDS.^21–31 Furthermore, the demographic characteristics of infants who die in child care are now similar to those who die at home, with the exception of age and time of death. Infants in child care are, on average, >1 month older than infants who die at home. This may reflect the typical age of entry into child care; 47% of infants in child care enter care between 3 and 6 months of age.⁵ It is also not surprising that the child care deaths are more likely to occur between the hours of 8 AM and 4PM, as the vast majority of nonparental child care occurs during these hours.

It is unclear why child care places infants at risk for SIDS, when the demographic characteristics and sleep environment suggest that these infants should be at the same and perhaps even lower risk for SIDS. However, similar findings were reported in the Netherlands, where infants who died of SIDS in child care settings were more likely to be found in safer sleep environments than those who died at home.³² Other countries have not reported data regarding SIDS in child care settings. This may reflect the relative paucity of child care for infants in countries where mothers are allowed longer maternity leave,^33–36 often with partial or full pay. The average maternity leave in other countries in the Organisation for Economic Cooperation and Development is 44 weeks (10 months), with paid leave averaging 36 weeks.³⁷ Thus, the infant is not in child care during the first 6 months of life, when the risk for SIDS is greatest. In the United States, parents can receive up to 12 weeks per year (unpaid) for family leave, which includes maternity leave. Although federal Temporary Assistance to Needy Families guidelines allow states to exempt low-income mothers from working until their infant is 1 year of age, some states exempt mothers from employment for as little as 3 months.³⁸

In our initial survey, we found that infants who died in child care settings often did so during the first week in child care. Unfortunately, we were unable to obtain data on this phenomenon for this cohort. It is possible that the stress inherent in the change to a child care setting may predispose one to SIDS. Recent change in normal routine has been seen more commonly in infants who die of SIDS than in control infants.³⁹ It has been hypothesized that recent life changes result in sleep deprivation,⁴⁰ which in turn can result in deeper sleep and decreased arousal.^40,41 In addition, infants who are in child care have a higher rate of certain infections than those who are not in child care.^42,43 Increased levels of bacterial toxins have been found in victims of SIDS⁴⁴; although this does not account for the deaths in the first week of child care, higher infection exposure level may predispose infants who are in child care to SIDS.

Although the majority of child care deaths continues to occur in family child care homes, the proportion has decreased. It is unknown what proportion of SIDS occurs in unregulated family child care homes as compared with regulated family child care homes. However, it is estimated that at least 30% of family child care homes are unregulated.⁴⁵ In addition, many other child care arrangements, such as nanny care, relative care, and friend care, are unregulated. It is interesting to note that the proportion of SIDS that occurs while the infant is under the care of nannies/babysitters has increased, and the proportion in relative care has remained unchanged. The Back to Sleep campaign has targeted its mailings and educational efforts toward regulated child care centers and family child care homes. Those who provide relative care and unregulated family child care have no formal access to and may be unaware of training, education, and resources, such as Back to Sleep information, that are readily available through the child care community.⁴⁶ Unfortunately, it is the low-income families, because of limited financial resources and inconsistent work hours (which often include evening and weekend shifts), who disproportionately use unregulated and relative care.^46–48 Relative care providers and unregulated providers tend to be older than regulated family child care and child care center providers^46,49 and may not have had personal experience with supine infant sleeping. In addition, infants during their first year in child care will, on average, be in >2 nonparental child care arrangements.⁶ Infants whose mothers are employed part time or who work variable hours are much more likely to be in multiple child care arrangements.⁶ It is imperative that parents emphasize safe sleep practices for all who care for their infants. Even if an infant has a single nonparental child care arrangement, there may be multiple caregivers. The average annual turnover rates for child care center staff is 30%⁵⁰ and higher in unregulated settings.⁴⁶ Therefore, SIDS risk reduction training of child care providers should be repeated on a regular basis; one cannot assume that a single training session will be adequate in maintaining safe sleep procedure in a center.

Our conclusion that a disproportionate number of infants die of SIDS in child care settings is limited by not having age-matched controls or, alternatively, by not matching the proportion of infants in child care to all deaths by census tract. In addition, our calculations that <10% of SIDS cases should occur in child care is based on assumptions that both SIDS and time spent in child care are distributed equally throughout the day. However, neither of these is true, and this may slightly affect the proportion of SIDS deaths that should occur in child care settings. In addition, because of a decline in public funding for SIDS support, some states that participated in our previous survey were unable to participate in this most recent survey. However, this sample was geographically diverse and comprised 25% of all SIDS cases nationally in 2001.

The proportion of SIDS in child care is declining slightly but remains high. Efforts to educate child care providers can be effective in changing behavior,⁵¹ and these efforts should continue on a repeated basis. In addition, efforts must be made to reach unregulated child care providers. Parents must discuss sleep position with all who care for their infant. Alternative providers, such as foster parents, relatives, and friends, should be made aware of the importance of a safe sleep environment. Finally, efforts to enact state regulations with regard to safe sleep environment for infants in child care must be ongoing.

	ACKNOWLEDGMENTS

 
This study was funded by a grant from the Gerber Foundation.

We thank the staff of the following state SIDS centers for assistance in data abstraction: California SIDS program (Gwen Edelstein and Cheryl McBride); Colorado’s SIDS program (Sheila Marquez); Delaware Division of Public Health (Cathie Frost); Idaho EMS Bureau (Boni Carrell and James Aydelotte); SIDS Network of Kansas (Christy Schunn); Louisiana Office of Public Health (Tracy Hubbard); Massachusetts Center for SIDS (Mary McClain); Center for Infant and Child Loss, Maryland (Donna Becker); Michigan SIDS Alliance (Mary Adkins); North Dakota Department of Health (Toni Vetter); New Mexico Grief Services Program (Nancy Barickman and Elizabeth Apodaca); and Pennsylvania Department of Health (Milo Woodward and Myra Yingling).

	FOOTNOTES

 
Accepted Jun 2, 2005.

Address correspondence to Rachel Y. Moon, MD, Division of General Pediatrics and Community Health, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: rmoon{at}cnmc.org

The findings in this manuscript were presented in part at the International SIDS meeting; July 2–6, 2004; Edmonton, Alberta, Canada.

No conflict of interest declared.

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TOP ABSTRACT METHODS RESULTS DISCUSSION REFERENCES

 

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