Background. Since the Back to Sleep (BTS) campaign was initiated in 1994, the rate of prone sleeping has decreased to approximately 20%. However, child care centers may have an increased rate of prone sleeping in infants. In 1996, a study of licensed child care centers demonstrated that 43% were unaware of the association between sudden infant death syndrome (SIDS) and prone sleeping and that 49% positioned infants prone.
Objective. To determine effectiveness of a mailing from the BTS campaign to licensed child care centers by assessing the following: 1) child care center awareness of the recommendations of the American Academy of Pediatrics regarding infant sleep position and 2) implementation of the recommendations of the American Academy of Pediatrics in child care center practice.
Design. A descriptive, cross-sectional survey of licensed child care centers in the metropolitan Washington, DC, region. All licensed child care centers caring for infants <6 months old in Washington, DC, and Montgomery, Prince Georges, Howard, Anne Arundel, Frederick, and Charles Counties in Maryland were recruited for the study.
Results. Out of 236 eligible centers, 172 completed the survey. Seventy-five percent (129) of the centers were aware of recommendations regarding infant sleep position. Infants were placed prone in 27.9% of centers, although only 2.9% placed infants exclusively in the prone position. The most common reasons for avoiding prone position entirely were SIDS risk reduction and licensing regulations. Half of the centers had a written policy regarding sleep position. Twenty centers who were aware of the dangers of prone sleeping continued to placed infants prone at least some of the time, largely because of parental request. Only 56.9% of centers had heard of the BTS campaign despite the mass mailing. The mailing resulted in policy change for 14 centers.
Conclusions. Since 1996, the percentage of licensed child care centers in the greater Washington, DC, area that are aware of the association between SIDS and infant sleep position has increased from 57% to 75%. In addition, the rate of placing infants prone in these centers has declined from 49% in 1996 to 27.9% in this study. When child care centers are aware of the risk of prone sleeping, the most likely reason for continued prone placement is parental request. Although media and mailings have been largely effective in communicating BTS information to many child care centers, nonprone positioning is not universal among child care providers. Additional educational efforts toward child care providers and parents remain necessary.
In 1992, the American Academy of Pediatrics (AAP) published a recommendation to place all healthy infants in the supine or side position for sleep, because the prone sleep position is associated with an increased risk of sudden infant death syndrome (SIDS).1 This recommendation was modified in 1996 to state that supine position was preferred over the side position for sleep.2 In 1994, a national public education campaign, “Back to Sleep” (BTS), was launched through a coalition of the US Public Health Service, the AAP, the Association of SIDS and Infant Mortality Programs, and the SIDS Alliance. Since that time, the incidence of prone sleeping has decreased from approximately 70% in 1992 to approximately 20% in 1996.3–5 Concurrently, the incidence of SIDS in the United States decreased approximately 40% from a rate of 1.2 per 1000 live births in 1992 to .69 per 1000 live births in 1996.6
In the United States, the number of women in the labor force with children <6 years old has more than tripled from 2.9 million in 1960 to 10.3 million in 1996.7 Approximately half of working mothers have children of preschool age,7 many of whom are cared for by licensed child care centers. From 1977 to 1992, the number of child care centers more than doubled from 25 000 to 51 000.8 However, many states, including the District of Columbia and Maryland, have no regulations about sleep position in child care centers.9,10 A prior study showed that almost half of licensed child care providers in the metropolitan DC area were placing infants prone for sleep at least some of the time.11 Partly because of the results of this study, the BTS campaign in 1999 targeted mailings toward licensed child care centers, informing them of the risks of prone sleeping. In addition, there has been widespread local media attention to deaths in child care after 2 infants recently died in a family child care provider's home.12
The purpose of this follow-up study was to determine if the recent efforts by the BTS campaign and media attention have changed child care provider behavior. We hypothesized that a substantial proportion of child care centers continue to place infants in the prone position for sleep. This is especially important because 20% of SIDS occurs in child care settings.13 In addition, infants unaccustomed to prone position may be at very high risk of SIDS if placed in the prone position14; in past reports, infants are often placed prone for the first time in child care.13,15Identification of the prevalence of prone placement in child care centers is critical so that further health promotion efforts can be appropriately directed.
This project was a descriptive, cross-sectional study of all licensed child care centers caring for infants <6 months old in Washington, DC, and the surrounding Maryland suburbs. The survey was conducted from April through June, 1999. The institutional review board of Children's National Medical Center approved this study. The child care centers in these particular jurisdictions were chosen because they had received BTS mailings within 6 months of the survey. No family child care home providers were included in this study. Lists of child care centers from the District of Columbia (Department of Consumer and Regulatory Affairs, Service Facility Regulation Administration) and Montgomery, Prince Georges, Howard, Anne Arundel, Frederick, and Charles Counties in Maryland (Department of Human Resources, Office of Licensing, Child Care Administration) were used (Fig 1). The lists used for this study were identical to the ones used by BTS for their mailing.
The survey used for this study was similar to that used in our prior study in 199611 and consisted of 14 questions regarding age and number of infants cared for and details regarding any sleep position policies. We also asked specifically about prior knowledge of BTS or infant sleep position from mailings or the media.
We initially contacted each child care center for a telephone interview within 4 months of the BTS mailing. Centers with disconnected telephone numbers were deemed ineligible. The study investigators conducted all telephone interviews; interviews were conducted with center directors or with supervisors familiar with infant care. Directors of nonresponding centers were sent a questionnaire through the mail, which they were asked to return. A maximum of 2 mailings spaced 1 month apart was sent. All interviews were completed within 6 months of the BTS mailing. The telephone and mail interviews were identical in nature. Verbal consent for telephone respondents was obtained, and an information sheet regarding the purpose of the study was provided to mail respondents.
Outcome measures for this study were as follows: 1) awareness of the AAP recommendation regarding infant sleep position and 2) implementation of the AAP recommendation in child care center practice. Statistical analysis, including χ2 andt tests, was performed.
Of 326 centers listed as caring for infants, 74 did not care for infants until after 6 months of age and an additional 16 centers had disconnected telephone numbers, leaving a total of 236 eligible centers. One hundred twenty-seven centers answered the survey by telephone, and an additional 45 responded by mail, for a response rate of 172 (75%). Five centers refused, and the other 58 did not respond despite multiple telephone calls and 2 mailings. The response rate varied by county, with Prince Georges and Montgomery Counties least likely to respond (64.7% for both); 100% of the eligible centers in Charles County participated in the survey (Table 1). The minimum age for infants in the surveyed centers ranged from 4 to 16 weeks, with a mean of 7.1 (standard deviation [SD]: 2.1) weeks. A total of 758 infants <6 months old were in attendance at these centers at the time of survey. Infants <6 months old averaged only 5.4% of the total number of children at the surveyed centers. The mean total number of children at each center was 81.8 (SD: 59.97), with a range of 5 to 350 children. The number of infants <6 months old at each center ranged from 0 to 54 infants, with a mean of 4.41 (SD: 5.52) infants.
Infants were placed prone at least some of the time in 27.9% (48) of surveyed child care centers, with 2.9% (5) exclusively placing infants prone and another 2.9%5 placing them in either prone or side position (Table 2). An additional 11 (6.4%) placed infants in any position, including the prone position, as desired by the parent or child care provider, and 27 (15.7%) generally placed infants supine and/or side but placed infants prone if the parent requested. Infants were placed on the side at least some of the time in 62.2% of centers, with 26.7% exclusively placing infants on the side.
Reasons for infant positioning varied, and 47 (27.3%) of centers cited more than one reason motivating their choice of infant sleep position. The most commonly cited reasons included SIDS risk reduction or safety reasons (75%), parental choice (23.3%), fear of choking (14.5%) and fear of suffocation (12.8%). The most common combination of reasons was SIDS/safety and parental choice; 12 (6.9%) centers cited both.
Reasons for infant positioning also varied according to sleep position policy (Table 3). Of the 5 centers that placed infants prone exclusively, 3 did so because of infant comfort, stating that the infant slept better that way. One center that placed infants prone cited fear of choking; the other cited SIDS risk reduction. Of the 43 centers that sometimes placed infants prone, 21 (48.8%) did so because of parental request. Centers were more likely to place infants prone at least some of the time if they were located in less urban areas (P < .0001) and if they were smaller (P < .0001). Centers who placed infants exclusively prone had a mean of 3 infants, as opposed to 4.09 infants for those who sometimes placed infants prone and 4.61 infants for those centers that never placed infants prone.
Of the 124 centers that never placed infants prone, 101 (81.5%) did so because of SIDS-related recommendations (Table 3). Other reasons for avoiding prone positioning entirely included licensing regulations (9.7%), fear of choking or suffocation, infant comfort, and physician direction. Two centers that never placed infants prone could not state a reason. Centers were more likely to never place infants prone if they had previously heard of BTS (P < .0001) or if fear of suffocation was cited as a reason (P < .0001). Centers caring for more infants <6 months old were also more likely to have place infants supine (P < .0001).
Half of centers (86, 50%) had a written policy regarding sleep position. These centers tended to care for a large number of infants (P < .0001) and to be located closer to urban areas (P < .0001). Of the centers with written policies, 47 exclusively placed infants supine. An additional 3 centers placed infants supine unless a physician note was provided, 7 allowed parental choice as an exception, and 8 required a written parental waiver. Ten centers had policies allowing back or side, with an additional 2 allowing side positioning only if the infant was propped to maintain the side position. Four centers had a side-only policy, with an additional 2 allowing physician or parent waiver as exceptions to side. One center had a written policy stipulating prone positioning, and another placed infants either in the prone or side position. Three centers had parental choice as their written sleep policy. Eighteen centers required a written waiver from the parents if a position excluded from the center policy was requested. Centers were more likely to require written waivers if they cared for more infants (P < .0001) or if they had heard of BTS (P < .0001). The most commonly cited reasons for center written policy included SIDS-related recommendations or safety (72, 85.7%) and corporate policy (8.3%).
Only 97 (56.4%) of the centers had heard of the BTS campaign, and only 75 (43.6%) recalled having received a mailing from BTS in the prior 6 months. This contrasts to the 129 centers that had cited SIDS risk reduction as a reason for their policy earlier in the survey; it is possible that some of them were unfamiliar with BTS as the campaign to reduce prone sleeping. Of the 75 that had received the mailing, 60 (80%) had previous knowledge of BTS. The mailing did not affect policy in 31 centers, and in 30 others, it reinforced what the centers were already doing or gave the centers an opportunity to discuss the importance of nonprone sleep positioning with the parents. Ten centers changed their policy to supine sleep, 2 changed from parental choice, 1 removed bumper pads from the cribs, and 1 began requiring written parental waivers as the result of the mailing. However, knowledge of BTS did not increase the implementation of written policy. In fact, centers that had heard of the BTS campaign were less likely to have a written policy regarding sleep position (P = .0495).
Ninety-six (55.8%) of the centers had read or heard of the recent articles in the Washington Post12regarding sleep position, SIDS, and child care. As a result of the media coverage, 11 centers changed their policy to supine sleep, 6 discontinued use of quilts or fluffy blankets in the cribs, and 1 center did both. Almost half (45, 46.9%) of the centers who had read the newspaper articles felt that the information was helpful in reinforcing current center policy or justifying center policy to parents.
Twenty centers that cited SIDS risk reduction as a reason for their sleep position policy continued to place infants prone at least some of the time. Almost all of these (18) did so because of parental request.
At the end of the survey, respondents were asked the best means for updating child care providers on new medical information. 163 (94.8%) preferred direct contact via mail, fax, e-mail, or telephone, with mail being the most preferred method (158, 91.9%). Other responses included media, training sessions, and information provided through licensing agencies.
Many child care providers have learned about the importance of placing infants in the nonprone position for sleep. We found that the percent of child care centers placing infants prone at least some of the time has decreased from 49% in 199611 to 27.9% in this study. Although this is a significant improvement, the nonprone position is still not used universally in licensed child care centers, and only 33.7% of centers exclusively place infants in the supine position. This is disturbing, especially as the proportion of SIDS in child care has not decreased despite a decline in the national SIDS rate.13 There is evidence to suggest that infants unaccustomed to the prone position are at extremely high risk of SIDS if placed prone.14 Infants who die of SIDS in child care are often placed prone for the first time in child care.13,15
It appears that there are several reasons for centers to continue to place infants prone. The first reason is that many child care providers still do not know about the dangers of prone sleeping. Almost half (43.6%) of child care centers had not heard of the BTS campaign. These same child care centers, for the most part, had no recollection of receiving any information through the mail from BTS. We used identical mailing lists as were used for the BTS mailings. In addition, as we spoke with center directors and supervisors familiar with infant care, it is likely that they would recall any information regarding infant care that had been received. Perhaps those centers unfamiliar with BTS received the mailing but did not recognize its importance and threw it away without reading it. Although some providers familiar with the AAP guidelines regarding infant sleep position may not have recognized BTS as the campaign to promote supine sleep, 44 (25.6%) in our survey did not communicate recognition of either.
The second reason that child care providers continue to place infants prone appears to be parental choice. Forty of the centers had verbal policies (and 16 had written policies) allowing infants to be placed prone at the parent's request. Many of these were centers that were aware of the dangers of prone sleeping. This clearly places centers in an awkward and difficult situation. In fact, many of the center directors acknowledged that they appreciated the information sent by BTS because it gave them an opportunity to reinforce the importance of back sleeping to parents. Many of them had displayed the information on bulletin boards or other prominent places; others had included the information in newsletters or other information provided to parents. In addition, many centers (18 in our survey, compared with none in 199611) required parents to sign waivers if they requested that their infant be placed prone.
Although the prone sleeping rate has declined in the 3 years since our previous study,11 the percentage of centers placing infants on the side has not changed; 58% of centers in 1996 placed infants on the side at least some of the time, compared with 62.2% in this survey. This is concerning, because the side position is not a stable one, and many infants <6 months old who are placed on the side for sleep roll into the prone position.2 Again, if the infant is not accustomed to prone sleep, this places them at a higher risk for SIDS.14 Because this survey was intended to evaluate center policies, we did not ask how often side sleeping infants awoke in the prone position. Prone prevalence in these centers may have thus been underestimated.
It is interesting to note that no centers in this survey cited parental request as a reason for never placing an infant prone. This is in sharp contrast with our 1996 study, where 52% of centers cited parental request. It is possible that, because many more centers have nonprone policies in place, parents no longer feel compelled to stipulate that their children never be placed prone.
Media exposure also has helped to reinforce much of the BTS information. Eleven centers changed their sleep policies to back after reading the Washington Post articles, 6 centers stopped using soft blankets in the cribs, and 1 center did both. Indeed, it is difficult to determine how much of the decline in prone positioning in the centers is attributable to increased national awareness of SIDS and the importance of infant sleep position rather than to the recent BTS mailing.
We found it difficult to reach many centers, primarily in the District of Columbia and Montgomery and Prince Georges Counties, by telephone. Many of them did not answer, nor did they have answering machines for their telephones. We found this curious and wondered if parents were given a telephone number different from the official phone number to call in case of emergency. In addition, child care centers in these jurisdictions, when they answered the telephone, were less likely to be willing to participate in the survey. Many of the centers had policies designating 1 person (usually the center director) who could answer surveys. We did not experience this with less urban centers. We speculate that centers located closer to urban areas may receive more solicitation or survey calls and therefore have had to develop policies to deal with these calls.
Like any survey, the validity of these results is limited by the accuracy of the participants' responses. Questions were phrased in a manner designed to encourage truthful responses, but we acknowledge that centers aware of the recommendations may not have revealed if they placed infants prone. In addition, recent media attention on child care centers may have also deterred some centers, especially those using the prone position, from participating in our survey. We may have therefore underestimated the actual prevalence of prone use in child care centers.
It is clear that although media and mailings have been effective in communicating the BTS information to many child care centers, other methods may need to be used to reach all child care providers. Providers in our survey appreciated direct contact via telephone, email, fax, or mail. Workshops, meetings, and training sessions for child care providers may be helpful. In addition, working with licensing agencies and legislative bodies may be effective in providing new information to all child care providers.
We would like to thank Jacqueline Richter, Maryland Department of Human Resources, Office of Licensing, Child Care Administration, for her assistance in obtaining child care center lists.
- Received September 21, 1999.
- Accepted December 24, 1999.
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:
- AAP =
- American Academy of Pediatrics •
- SIDS =
- sudden infant death syndrome •
- BTS =
- Back to Sleep (campaign) •
- SD =
- standard deviation
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- Copyright © 2000 American Academy of Pediatrics