Background. Millions of children in the US have parents who work alternative shifts. As a result, extended-hour and nighttime child care centers have increased in number to meet the needs of parents working nonstandard hours. Recognizing that 20% of sudden infant death syndrome (SIDS) occurs in child care settings and that child care providers may place infants prone, it is important to determine sleep position practices in nighttime child care centers.
Objective. To determine if nighttime child care centers 1) follow Back to Sleep recommendations; 2) are aware of the need for a safe sleep environment; and 3) have written policies directing proper SIDS risk reduction practices.
Design. A descriptive, cross-sectional survey of licensed child care centers in the US offering evening and nighttime care. All nighttime centers caring for infants <6 months old were recruited for the study.
Results. Out of 153 eligible centers, 110 centers in 27 states completed the survey. Infants were placed prone in 20% of centers, although only 1 center placed infants exclusively prone. Infants slept in cribs in 53.6% of centers, but slept in uncluttered sleep environments in only 18.2% of centers. Smoking was prohibited in 86.4% of centers. The most commonly cited reason for avoiding prone altogether was SIDS risk reduction; however, 10 centers that cited SIDS risk reduction continued to place infants prone at least some of the time, because of parental request or concerns about infant comfort. Over half (59%) of the centers had written policies; however, presence of written policy was not associated with avoidance of prone position. In over one third of centers with written policies, providers were unaware of the content of the policy.
Conclusions. Twenty percent of nighttime child care centers place infants prone at least some of the time. Most providers who place infants prone do so because of lack of awareness or misinformation about safe sleep environment. Although the Back to Sleep campaign has been effective in communicating the risks of sleeping prone, nonprone positioning is not universal among nighttime child care providers. Additional educational efforts toward child care providers remain necessary. In addition, parents as advocates for their own infants need to be proactive in assuring that safe sleep practices are implemented in child care settings.
As the American workplace has changed, so have the needs of the workforce. With mothers of 47% of infants under 1 year old in the workforce,1 the need for responsible child care providers has escalated. With businesses run around the clock and the workday extended, the “alternative shift” (defined as work hours outside of the regular day shift)2 has become more common. As many as 5.5 million women with children under 6 years old work full-time in alternative shifts.2 An additional 6.5 million women with children under 6 years old work part-time,3,4 many of these during the evening and night hours. As the need for nonstandard hours of child care has become a higher priority, extended-hour and nighttime child care centers have increased in number to meet the needs of parents working alternative shifts. By 2001, 45 states had licensing provisions for evening and nighttime operation of child care centers.5
Recognizing that 20% of deaths from sudden infant death syndrome (SIDS) occur in child care settings,6 the need to assure SIDS-knowledgeable child care providers, particularly when infants will be left overnight, becomes an issue of national concern. It is well-known that subsequent to the American Academy of Pediatrics recommendations in 1992 and the Back to Sleep (BTS) educational campaign in 1994,7 the incidence of SIDS dramatically decreased in the US from 1.2 SIDS deaths per 1000 live births (1992) to 0.53 per 1000 live births (2000).8 This reduction was directly related to the decreased frequency of prone sleeping from 70% (1992) to 17% (1998).9 Despite this remarkable progress in SIDS risk factor education and practice, a 1996 study revealed that 43% of licensed child care centers lacked awareness of the association of SIDS and infant sleep position,10 and a follow-up study in 1999 documented that despite an increased awareness, 25% of licensed child care centers continued to place infants prone to sleep.11 Furthermore, licensed child care centers seldom have adequate regulations regarding safe sleep for infants.12
Recognizing that licensed standard-hour child care provides suboptimal implementation of SIDS risk factor reduction recommendations, we hypothesized that, as compared with daytime child care centers, nighttime child care centers would have 1) similar nonadherence with the BTS recommendation; 2) lack of knowledge regarding safe sleep environment; 3) lack of knowledge of SIDS risk reduction recommendations; and 4) lack of policies to direct proper SIDS risk reduction practices. We anticipated that identification of deficiencies and educational needs would direct further educational efforts with nighttime child care providers regarding SIDS risk reduction.
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.
Child Care Center Demographics
Forty-five states were identified by the 2001 Child Care Center Licensing Study5 as licensing child care centers for evening and nighttime operation. State licensing bureaus and Child Care Resource and Referral centers in each of the 45 states were contacted. Of the 45 states, 35 (78%) states had centers currently licensed for extended-hour care. Among these 35 states, 722 centers were identified and contacted for study inclusion. Of the 722 centers, 305 were ineligible because they closed before 10 pm (n = 215) or because they did not care for infants <6 months old (n = 90). An additional 208 centers did not respond despite multiple telephone calls, and 56 centers had disconnected or incorrect telephone numbers.
Of the 153 centers that were contacted and eligible for participation, 110 centers in 27 states agreed to participate in the study, for a participation rate of 71.9%. These 110 centers provided representation from the northern (34 centers in 12 states), southern (63 centers in 11 states), and western (13 centers in 4 states) US. Of the 110 centers, 33 were open 24 hours, an additional 46 were open until midnight or later, and the remainder were open until 10 pm. Centers had been in business for 0.5 to 37 years, with a median of 6.5 years (25th percentile of 3.0, and 75th percentile of 12.0). The minimum age for infants in the surveyed centers ranged from “newborn” to 12 weeks old, with a median of 6.0 weeks old and a mean of 4.7 (standard deviation 2.71) weeks old. A total of 800 infants <6 months old were in attendance at the 110 participating centers at the time of the survey; 193 infants (24.1% of all infants cared for) were in care after 10 pm. The number of infants <6 months old at each center ranged from 0 to 50, with a mean of 7.92 (standard deviation 8.88) infants.
Adherence With SIDS Risk Reduction Recommendations
Infants were placed prone at least some of the time in 22 (20%) of the surveyed child care centers, including 1 center exclusively placing infants prone, 4 (3.6%) placing them in either prone or side position, and 17 (15.4%) placing infants in any position, including the prone position, as desired by the parent or provider (Table 1). Infants were placed on the side at least some of the time in 71 (64.6%) centers, with 29.1% exclusively placing infants on the side. Infants were placed exclusively on the back in 36 (32.7%) centers.
Infants slept in cribs in more than half (59, 53.6%) of the surveyed centers. The other centers placed infants for sleep in playpens or portable cribs (7, 6.4%), “infant beds” (3, 2.7%), infant swings (3, 2.7%), bassinets (1, 0.9%), or an unspecified non-crib area (40, 36.4%).
Infants slept in uncluttered sleep environments (not even a blanket) in 20 centers (18.2%). In 74 (67.2%) centers, infants slept with blankets; in 9 of these centers, a “thin” blanket was specified, and 1 center allowed comforters. Eleven (10%) centers allowed stuffed toys in the sleep environment, and 2 (1.8%) allowed pillows. Other objects allowed with sleeping infants included pacifiers (6, 5.5%), bumper pads (2, 1.8%), wedges (1, 0.9%), and unspecified items (7, 6.4%).
Smoking was prohibited on the premises during hours of operation in 95 (86.4%) centers. Smoking was allowed in outdoor designated areas in 9 (8.2%) centers, and 5 (4.5%) centers allowed smoking if it was out of the view of children. There were no restrictions on smoking in 8 (7.3%) centers. One center required employee hand-washing after smoking.
Knowledge of SIDS Risk Factors and Rationale for Implementation of Safe Sleep Practice
Knowledge of Risk Factors
Forty-three (39.1%) of the centers had heard of the BTS campaign, but only 26 (23.6%) recalled having received any written information from BTS (most in the prior year). Of the 26 that had received the BTS mailing, 15 (57.7%) had previous knowledge of BTS, 3 (11.5%) changed their policy to supine sleep, and 5 (19.2%) reinforced current practice/stressed importance of nonprone sleep positioning with staff and parents. Knowledge of BTS was associated with supine sleep positioning (P = .003), but was not associated with the presence of written policy.
Centers also reported that they had received information regarding safe infant sleep practice from other sources, including training sessions (35, 31.8%), media (16, 14.5%), state/corporate regulations (4, 12.7%), and physicians/medical personnel (11, 10%). This information resulted in a change to nonprone positioning in 20 centers (18.1%), and avoidance of the prone positioning for those who cited “training” as the source of their information (P = .02). However, training did not increase the implementation of written policy.
Rationale for Implementation of Safe Sleep Practice
Reasons for infant positioning varied, and 20 (18.2%) centers cited >1 reason motivating their choice of infant sleep position. The most commonly cited reasons included SIDS risk reduction or safety reasons (70%), fear of choking (13.6%), and fear of suffocation (13.6%). The most common combination of reasons was SIDS risk reduction and fear of suffocation; 8.2% of centers cited both (Table 2).
A variety of reasons accounted for why a center might allow prone positioning for sleep. The 1 center that always placed infants prone did so because of previous experience. In the 21 centers that sometimes placed infants prone, the most common reasons for choosing sleep position were SIDS- or safety-related recommendations (28.6%), parental request (19%), infant comfort/infant “slept better” (19%), and fear of choking (14.3%). Centers were more likely to place infants prone at least some of the time if they were open for 24 hours (P = .03) or if they cared for more infants <6 months old (P = .003). Ten 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. Most of these did so because of parental request or concerns about infant comfort.
Of the 89 centers that never placed infants prone, 76.4% did so because of SIDS-related recommendations. Other commonly stated reasons for avoiding prone positioning entirely included fear of suffocation (14.6%) and fear of choking (13.5%). Centers were more likely to never place infants prone if SIDS was cited as a reason for their sleep position practice (P = .03). Of the 31 centers that did not cite SIDS or safety as a reason for their practice, 10 (32.3%) placed infants prone at least some of the time, 11 (35.5%) placed infants on the side, and 10 (32.3%) used supine or supine/side.
Policies to Implement SIDS Risk Factor Avoidance, Education, and Practice
Written policy regarding sleep position was reported in 65 (59%) centers. These centers with written policies were more likely to designate SIDS as a reason for sleep positioning (P = .02) or to have had previous knowledge of BTS (P = .04). Of the centers with written policies, 25 policies stipulated exclusive placement in supine, 1 placed infants supine unless a physician note was provided, and 1 allowed parental waiver as an exception to supine. Five centers had policies allowing back or side (including 1 that allowed parental waiver as an exception), 2 centers had a side-only policy, and 6 centers had parental choice as their written policy. In 25 centers, the child care provider answering the survey stated that there was a written sleep policy, but she or he did not know what the policy was. The most commonly cited reasons for center written policy included SIDS-related recommendations or safety (25, 22.7%) and corporate policy or state law (10, 9.1%). If a center had a written policy regarding sleep position, it was more likely to allow soft bedding (P = .03).
Presence of written policy was not associated with avoidance of the prone position. Indeed, when the child care providers in these 65 centers with written policies were asked about usual sleep positioning, 20 (30.8%) had stated that back was the usual position, 16 (24.6%) side or back, and 21 (32.3%) side only, including 6 centers which allowed parental waiver or child care provider choice to override the usual position. Seven additional centers allowed prone at least some of the time.
A policy limiting smoking was in place in 102 (92.7%) of the centers, with 94 of these advocating no smoking on the premises. Centers were more likely to allow smoking if they placed infants prone for sleep (P = .005).
State regulations requiring nonprone sleep position for infants were in place in 6 of the 27 states with surveyed child care centers, affecting 11 centers included in this study. Presence of state regulation was not associated with sleep position practice, nor was it associated with presence of written policy. However, if a center cited state or corporation regulation as a reason for how infants were positioned, it was more likely to have a written policy regarding sleep position (P < .0001).
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.
This work was supported in part by grants from the Gerber Foundation (Dr Moon) and the SIDS Alliance of Illinois (Dr Weese-Mayer).
We are grateful for the assistance of Dr Wendy Biliter, Joana Iglesias, Cynthia Knezevich, and Poutrise Peters, who shared the responsibility for the calls to the night care centers. We thank Kimberly Madenwald for her administrative assistance.
- Received May 28, 2002.
- Accepted September 27, 2002.
- Reprint requests to (R.Y.M.) Division of General and Community Pediatrics, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail:
- ↵Beers TM. Flexible schedules and shift work: replacing the “9-to-5” workday? Mon Labor Rev.2000;June 2000 :33– 40
- ↵Williams DR. Women’s part-time employment: a gross flows analysis. Mon Labor Rev.1995;April 1995 :36– 44
- ↵US Department of Labor, Bureau of Labor Statistics. Highlights of Women’s Earnings in 2000. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2001:1–39
- ↵The Children’s Foundation. Child Care Center Licensing Study. Washington, DC: The Children’s Foundation (National Child Care Advocacy Program); 2001
- ↵Moon RY, Patel KM, McDermott Shaefer SJ. Sudden infant death syndrome in child care settings. Pediatrics.2000;106 :295– 300
- ↵American Academy of Pediatrics, Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics.1992;89 :1120– 1126
- ↵Hoyert DL, Freedman MA, Strobino DM, Guyer B. Annual summary of vital statistics: 2000. Pediatrics.2001;108 :1241– 1255
- ↵Gershon NB, Moon RY. Infant sleep position in licensed child care centers. Pediatrics.1997;100 :75– 78
- ↵Moon RY, Biliter WM. Infant sleep position policies in licensed child care centers after Back to Sleep campaign. Pediatrics.2000;106 :576– 580
- ↵Moon RY, Biliter WM, Croskell SE. Examination of state regulations regarding infants and sleep in licensed child care centers and family child care settings. Pediatrics.2001;107 :1029– 1036
- ↵Hunt L, Fleming P, Golding J, and the ALSPAC Study Team. Does the supine sleeping position have any adverse effects on the child? I. Health in the first six months. Pediatrics.1997;100(1) . Available at: http://www.pediatrics.org/cgi/content/full/100/1/e11
- ↵Malloy MH. Trends in postneonatal aspiration deaths and reclassification of sudden infant death syndrome: impact of the “Back to Sleep” program. Pediatrics.2002;109 :661– 665
- ↵Kahn A, Groswasser J, Sottiaux M, Rebuffat E, Franco P, Dramaix M. Prone or supine body position and sleep characteristics in infants. Pediatrics.1993;91 :1112– 1115
- ↵American Academy of Pediatrics, Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics.1996;98 :1216– 1218
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