Is Your Day Care Safe for Sleeping Babies?

From the WebMD Archives

May 11, 2001 -- The specter of sudden infant death syndrome, commonly called SIDS, looms large in the imagination of many a new parent. Fortunately, parents can follow a few simple steps, outlined by the American Academy of Pediatrics, or AAP, to reduce the risk of SIDS: Put infants to sleep on their backs; get rid of fluffy, soft bedding and unsafe cribs; and eliminate second-hand smoke.

But the simple message hasn't filtered down to everyone. Though some SIDS cases occur in child care centers and family child care settings, many of these facilities are still unaware of the need for SIDS risk reduction. A new survey, published in the May journal Pediatrics, found that state regulations for licensing these child care facilities and ensuring that these recommendations are put into practice do not adequately address the issue of sleep safety for infants.

"We know from past studies that 20% of babies die of SIDS at child care centers, and we also know that a lot of child care providers, for various reasons, don't put babies to sleep on their backs and don't follow other safety guidelines that the AAP and the Consumer Product Safety Commission [CPSC] have been recommending," study author Rachel Y. Moon, MD, tells WebMD.

"One way to educate child care providers is through the regulatory process, [so] we looked at what states are doing on a regulatory basis to make sure that babies in child care centers are safe when they take naps," says Moon. Moon is an assistant professor of pediatrics at George Washington University and a pediatrician at Children's National Medical Center in Washington, D.C.

The researchers reviewed each states' regulations concerning four areas of sleep safety: sleep position for infants under six months old, crib safety, bedding safety, and smoking in facilities. "What we found was that a lot of states don't really regulate this very heavily; a lot states have very old regulations," says Moon. "I think there are only six states that stated babies should be placed to sleep on their back or on their side."

In 1992, the AAP issued its Back to Sleep program, which recommended that infants sleep on their backs. The program has dramatically reduced SIDS cases, but the AAP continues to make additional recommendations on safe sleep.

The AAP released more safe sleep recommendations in 2000. "They talked about bedding, smoking, room temperature," Moon says. "While we are not saying all should be part of [each state's] standards, the AAP sleep position has been out since 1992 -- almost 10 years -- and there are 15 states that still use regulations that were written before 1992."

In the U.S., 63% of states require child care center cribs to meet at least one CPSC safety standard -- which may include proper distance between the slats, no missing or cracked slats, a snug-fitting mattress, mattress support and all screws and bolts securely attached, and working latches -- and only six states had provisions limiting the use of soft bedding, as recommended by both the AAP and the CPSC.

The researchers found that 29% of states don't prohibit smoking in child care centers. Yet "there is more and more evidence that shows, besides sleeping [on the stomach], smoke is probably the next most important risk factor for SIDS, and we know that ... the more smoke a baby is exposed to, the higher the risk."

Just because state regulations fall short of the ideal doesn't mean that all day care and home care facilities are disasters waiting to happen, adds Moon. "The Back to Sleep [educational campaigners] in different states have done a lot of work in educating child care providers and have made a huge impact," she says, they just haven't been able to reach everybody.

Additionally, many of the large, well-known national chains have their own rules that go above and beyond state regulations. "Chains, larger centers, and centers that cater more towards infants are more likely to have standards about infant sleep," Moon says.

Jackie Legg is senior vice president of operations at Bright Horizons Family Solutions, a national provider of more than 350 early childhood programs, mostly in the U.S. "We always go along with state requirements, but in most every instance that relates to health and safety, we go beyond that," Legg tells WebMD.

"We support the AAP's sleeping position statement, and we actually require parents to sign a release if they don't want us to do that," says Legg. "There is a fine line between doing [back to sleep] and accommodating parents' specific wishes. We let them know the research on the implication of children sleeping on their stomachs and SIDS."

She says Bright Horizons' position on stuffed animals and soft bedding is similar: They can educate parents, but if someone insists on a certain stuffed animal, they allow it.

Both Legg and Moon say that a parent can -- and should -- play a big role in making sure their child benefits from safe sleep practices.

"Parent involvement is the key to everything in ensuring they get the kind of care they want for their children," says Legg. "I think it is perfectly allowable for parents to have conversations with their providers, whether it is a family day care provider or a center, to ask to see copies of their policies and procedures related to safety and health, to ask questions, and certainly to give directions to the caregiver on sleeping positions."

She says parents also should request that smoking not be allowed near their children. "They can certainly make those kinds of requests even if it is not a policy of the facility they are using. It could be that the facility says, 'we can't do that,' and that would be a decision point for the parent," says Legg.

"What I would say to parents is, you can't take anything for granted. You can't assume that just because your child care provider takes care of children they necessarily know about [safe sleep practices]," says Moon.

"I recommend that parents talk to child care providers about sleep positions just as they would about what they are feeding the baby, and make sure the child care provider isn't smoking. I also tell the child care provider that they need to have written policies in place, as a way of showing parents what they do, as a way of legally protecting themselves, and also as a teaching tool because some parents don't know.

"My feeling is, if there is a dialogue and the child care provider and parents are talking then they can teach and help each other create the best environment for the baby," says Moon.