Nighttime Child Care: Inadequate Sudden Infant Death Syndrome Risk Factor Knowledge, Practice, and Policies

METHODS

This project was a descriptive, cross-sectional study of licensed child care centers in the United States offering evening and nighttime care for infants <6 months old. The study was conducted from September 2001 through December 2001. The institutional review boards of Children’s National Medical Center and Rush-Presbyterian-St Luke’s Medical Center approved this study. Lists of licensed child care centers offering evening and nighttime care were obtained from state licensing bureaus and Child Care Resource and Referral Services. Those extended-hour centers that were open past 10 pm and cared for infants <6 months old were then contacted by telephone and asked to participate.

The survey used for this study was similar to those used in prior studies in 1996¹⁰ and 1999¹¹ and consisted of 21 questions regarding age and number of infants cared for, details regarding sleep practice and policies, and awareness of recommendations about infant sleep position. Questions were open-ended, and multiple reasons from each center were noted.

We contacted each child care center for a telephone interview. Centers with disconnected telephone numbers were deemed ineligible. Interviews were conducted with center directors or with supervisors familiar with infant care. Verbal informed consent was obtained.

Primary outcome measures for this study were: 1) knowledge and adherence with SIDS risk reduction recommendations, including sleep position, safe sleep environment, and tobacco smoke avoidance; and 2) presence of written sleep policies. Statistical analysis, including χ² and Student t tests, was performed. Significance was applied to P < .05.

RESULTS

DISCUSSION

Many child care providers have learned about the importance of placing infants in the nonprone position for sleep. We found that the percentage of nighttime child care centers placing infants prone at least some of the time was 20%, compared with 27.9% for daytime child care centers in 1999.¹¹ Although this is an improvement and reflects increased acceptance of the nonprone position, nonprone is not used universally in licensed nighttime child care centers, and only 32.7% 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.⁶ With the centers described in this current project providing care after 10 pm, when most infants are sleeping, many infants unaccustomed to the prone position are placed at extremely high risk of SIDS in those centers that place infants prone.¹³

There appear to be several reasons that nighttime centers place infants prone. The primary reason is that many providers still are unaware of the dangers of sleeping prone. Nearly 60% of the 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. Curiously, despite the limited number of centers that had heard of the BTS campaign, 77 of the 110 centers cited SIDS risk reduction as a reason for their practice. Although it is not entirely clear where these centers are learning about SIDS risk reduction, they profess knowledge of the recommendations. Unfortunately, their practice indicates that many of them do not understand the recommendations, since nearly 29% of centers cited SIDS/safety as the reason they sometimes used the prone position. In fact, in over one third of the centers with written policies, providers were unaware of the content of the policy. Although written policies are important as a tool to communicate with parents and with providers, they are useless if those charged with caring for infants do not understand the policies.

A related reason that nighttime providers continue to place infants prone is that they are misinformed as to the risks and benefits of the various sleep positions. A traditional reason for avoiding the supine position continues to be fear of choking. Multiple studies have established that there is no increased risk of choking or aspiration with the supine position.^14–16 Six child care providers cited infant comfort as a reason for not placing infants supine. Research has confirmed that prone infants sleep deeper and have higher arousal thresholds.^17,18 However, the difficulty to arouse may place infants at higher risk of lethal rebreathing.¹⁹

In addition, nighttime child care providers continue to be misinformed that side is a safe alternative. In our survey, 64.5% of the night care centers placed infants either always or sometimes on the side. This is alarming 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.²⁰ Again, if the infant is not accustomed to prone sleep, this places him or her at a higher risk for SIDS.¹³

It is remarkable that no centers in this survey cited parental request as a reason for never placing an infant prone. It is even more remarkable when one considers the limited number of centers having a written policy in place (59%), and the limited number of states mandating policy.¹² One possible explanation is that parents are satisfied if center policy or practice stipulates supine position and do not feel compelled to further request the nonprone position. Alternatively, parents may not be adequately informed to inquire about a center’s policy or to insist on specific positioning for their infant.

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, concern for exposure to public scrutiny may have prevented some centers from participating or answering truthfully. Therefore, we may have underestimated the actual prevalence of prone use in night care centers.

Another apparent limitation of our study is the presence of night care centers in only 35 states, and the observation that centers licensed for extended hours in 10 of these states did not actually offer evening or nighttime care, or limited such care to older children. As a result, our interviews were limited to the 35 states that met the criteria for inclusion into our study, and then further limited to participating centers in 27 of these states. However, it should be noted that despite that limitation, our sample is geographically diverse and represents 77% of the 35 states with any centers licensed for extended-hour care.

It is clear that there is significant room for improvement in education about SIDS risk factors and implementation of safe sleep practices for child care centers that offer nighttime care. These providers remain uneducated about safe sleep practices. Resources identified by providers were limited, with only 14.5% citing media, 13% state/corporate regulations, and 10% physicians/medical personnel. 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 that nighttime child care providers are typically exposed to. A more effective campaign to reach these centers is indicated and may need to include workshops, meetings, and training sessions directed specifically toward day and night child care providers. In addition, working with licensing agencies and legislative bodies may be effective in providing current information and verifying safe practices for all child care providers. Finally, parents as advocates for their own infants need to be more proactive in evaluating child care centers to ascertain that safe sleep practices are taught and implemented.