Infant Safe Sleep in Child Care Settings

Ann HalbowerProfessor of Pediatrics,

Pulmonary SectionChildren's Hospital Colorado The University of Colorado

School of Medicine

Colleen KapsimalisColorado Child Fatality

Prevention SystemColorado Department of

Public Health and Environment

Financial Disclosures

Funding: NIH, and Department of Pediatrics, UCD

Medical advisor: AVISA device company, unrelated

Ann C Halbower

Objectives Provide definition of Sudden Infant Death Syndrome

(SIDS), Sudden Unexpected Infant Death (SUID), and sleep-related deaths

Discuss risk factors and protective factors for SIDS

Identify common misconceptions about infant risk and safety

Discuss why child care providers are important

Share recommendations and available resources for child care providers

What is SIDS? What is SUID? SIDS: “The sudden death of an infant under one year of

age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history”

Hard to classify some infant deaths (some cases are called “SIDS” when the infant was accidentally suffocated)

SUID: Sudden Unexpected Infant Death- death from all causes including accidental suffocation

#1 cause of death of infants between one month and one year of age

National Institute of Child Health and Human Development, 1991

Sleep-Related Infant Deaths

Sudden and unexpected infant death (SUID)

Most occur during sleep◦ Suffocation, strangulation, entrapment◦ Undetermined◦ SIDS

SUID

AGE ImmatureNervousSystem Sleep

Cardio-RespiratoryControl

Environment Genetics

What causes SUID?

We know several “risk factors” Making SUID more likely: Some we cannot control

Premature birth (baby born more than 3 weeks early)

Low birth weight (less than 5 lb 8 oz)Young age of motherAfrican/Native AmericanRecent infection in babyUnemployment

Identifying Modifiable Risk FactorsNew Zealand Cot Death Study: 1987-1990 485 SIDS cases ------1800 controls

Association between SIDS and:

Smoke exposure Excess thermal insulation Prone sleeping position (face down)

(Mitchell et al, J Paediatr Child Health; 28: 1992)

Some Risk Factors for Infant Death

can be controlled

Smoke Exposure can be changed

Smoke exposure during pregnancy and after birth more than doubles the risk of infant death

(MacDorman et al, Am J Epidemiol; 146: 1997)

Smoke changes the brain areas responsible for breathing (Brain Pathol. 2008 Jan;18(1):21-31)

Smoke increases lung inflammation and swells the airway

Marijuana smoke is also a pollutant and changes the sleep/wake cycles (J Psychopharmacol. 2013;27(3))

Position of Sleep Can be Changed

Prone Positioning: Face Down on the Stomach

Prone Sleep and Death

Normal Infants sleeping prone have increased odds ratio of death 13:1

Former preterm infants sleeping prone have Eighty times the risk of sudden death compared to supine term infants

(Blair, Fleming, 2005)

Prone Position : Pro or Con?

strength of evidence

Increase in sleep duration +++Decreased wake episodes +++Reduced heat loss +++Better oxygenation ++Fewer apneic spells +/-Less GE reflux +

Healthy Mothers, Healthy Infants Coalition of North Florida

Paluszynska, Pediatrics 2004; 114:6

SIDS and the Prone Position

Pharyngeal collapsibility is increased in the prone infant, (worsened by head turned to side)

(Ishikawa, AJRCCM 2002)

SIDS and the Prone Position: ConsSignificant reduction in swallow, cough with

decreased protection of airway

Decreased arousal from sleep and response to abnormal blood gasses

(Milerad, 1989)

BP (worsened by HOB) increased HR

(Amemiya 1991; Horne and Franco 2002, White, Acta Paediatr; S389:1993, Grieve PG, Pediatr Neurol. 2007 Aug;37(2):91 )

More Modifiable Risk Factors

Use of pillows in bed (to prop infant or use as mattress) was associated with significantly increased risk of SIDS

Wedges are not advised

Hyperthermia and SIDS

High Body Temperature

Decrease sensitivity to CO2 and low oxygenDecrease protective cough reflexesIncrease periodic breathingIncrease deep sleep without arousalAssociation of hyperthermia to prone

position

Hyperthermia and SIDS

Head contributes to 40% of heat production in infant

Head is site of significant heat loss in an infant

Covering the head decreases the ability to vent excess heat

Hyperthermia can be Changed

SIDS infants were habitually more warmly wrapped than controls

SIDS infants slept with heat on higher

Quilts, thick duvets, or blankets that covered the head were associated with very high risk

Face Covering and SIDSCovering of head--- very strong risk, (more

than half SIDS victims moved down in bed under the covers and/or were found with face covered (Fleming, CESDI, 2000)

Covering face decreases arousal during sleep, increases heart rate, increases CO2, increases body temperature even when supine

(Franco, Pediatrics 109 (6), 2002) (Hauck, Pediatrics 111 5(part 2) Chicago 2003)

Modifiable Risk Factors for unexpected death in infantsSleep on soft bedding/mattressBed sharing with one or more peopleRisk of death increased if infant slept

alone in adult bedRisk of SIDS increased if infant slept in a

separate room (10.49)Risk sleeping on a sofa (50)

Dangers of Soft Bedding

• Infants dying from SIDS are more likely to have:◦ used a pillow or soft mattress◦ been found with nose and mouth completely covered

by bedding◦ assumed face-down posture

• Soft bedding increases risk of SIDS 5x, independent of prone position

• Also increases risk of suffocation, strangulation, and entrapment

Baby Propping

Propping babies for reflux:

No evidence that it improves refluxCar seats increase refluxAirway instability when head falls to sideChildren roll to bottom

Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years : 2005. Cochrane Collaboration

Child Care and SUIDBetween 2008-2012, the Colorado Child Fatality

Prevention System identified 15 children who died in child care environments due to sleep-related circumstances

The majority of these child care environments were licensed child care homes (13, 86.7 percent)

86.7 percent (13) of the supervisors were licensed child care workers

None of these cases met all of AAP’s recommendations for a safe sleep environment.

Child Care and SIDS - 21st Century

• Still high proportion of infants die in child care, but decreasing (Moon, 2005)

◦1/3 die in first week; of these, 1/2 die on the first day

• Sleep position is less an issue◦Relatives and non-licensed caregivers may still be

unaware of importance of supine• Infants in child care in safer sleep

environment◦More likely to be in crib◦Less likely to be in adult bed or sofa

Education Does Work!• Increases awareness and knowledge of

safe sleep practices• Changes provider practices• Encourages written policies (Moon, 2003)• Back-to-Sleep targeted child care providers• Healthy Child Care America Safe Sleep

Campaign• Problems:

◦Unregulated providers◦Frequent staff turnover

Findings from National Study of Child Care Providers

• Training child care providers improves knowledge and practicesSleep positionLessens use of loose and soft bedding

• No change in provider attitudes about whether sleep position makes a differencePolicies and regulations are critical!

• Barriers: perceived parental objections, provider skepticism, lack of policies and training opportunities (Moon, 2008)

Regulation and Legislation

• Child care providers are more likely to place infants on their backs to sleep if there is a regulation or written policy in place

• States with regulation or legislation regarding sleep position in child care has increased

• Colorado is currently in the process of modifying its child care licensing regulations and rules to include infant safe sleep recommendations

AAP Recommendations: Pertinent to Child Care

• Sleep position• Plagiocephaly• Pacifiers• Soft bedding• Overheating

Back to Sleep for Every Sleep

• To reduce the risk of SIDS and suffocation, back sleeping for every sleep

• Side sleeping is not safe and is not advised

• Supervised tummy time when babies are awake

What About Rolling Over?

• No data about when it is safe for infants to sleep in the prone or side position ◦ Studies all include infants up to 1

year of age• Infants should continue to be

placed supine until 1 year of age

• Once an infant can roll from supine to prone and from prone to supine, the infant can be allowed to remain in the sleep position that he or she assumes

Avoidance of Plagiocephaly

Encourage “tummy time” when infant is awake and observed. This will also enhance motor development.

Car Seats and Bouncers

• Avoid having infant spend excessive time in car seats and “bouncers,” where pressure is applied to occiput

• Upright “cuddle time” is encouraged

Use a Firm Sleep Surface• To reduce SIDS and suffocation • Firm crib mattress, covered by fitted sheet

◦ A crib, bassinet, portable crib, or play yard that conforms to CPSC safety standards

◦ Check for recalls◦ Do not use cribs with missing hardware; don’t try to fix

broken cribs• Use mattress designed for specific product

◦ Mattress should be firm and maintain shape even when fitted sheet is used

• No pillows or blankets in addition to or instead of mattress under the infant

• No adult beds – risk of entrapment and suffocation

Sitting Devices for Sleep• Car safety seats, strollers, swings, infant carriers, infant

slings• Not recommended for routine sleep in the hospital or at

home • Infants < 4 months are particularly at risk

◦ More likely to assume positions that can create risk of suffocation or airway obstruction

• Infant slings and cloth carriers:◦ Ensure that the infant’s head is up and above the fabric, the

face is visible, and that the nose and mouth are clear of obstructions

◦ Reposition baby after nursing • If an infant falls asleep, move infant to a crib or other

appropriate flat surface as soon as is practical • Car safety seats and similar products are not stable on a

crib mattress or other elevated surfaces

Pacifiers

• Studies consistently demonstrate a protective effect of pacifiers on SIDS

• Mechanism unknown◦Decreased arousal

threshold (Franco)◦Pacifiers dislodge within 15

minutes (Weiss and Kerbl) to 1 hour (Franco et al) of sleep

Consider Offering a Pacifier at Naptime and Bedtime

• Use when placing the infant for sleep ◦ Does not need to be reinserted if it falls out after baby is

asleep◦ Do not force pacifier use

• Do not hang pacifier around the infant’s neck ◦ Do not use pacifiers that attach to infant clothing with

sleeping infants• For breastfed infants, delay pacifier introduction until

breastfeeding is firmly established, usually by 3 to 4 weeks of age

Do not use pacifier attachments

Avoid Overheating

• Increased risk of SIDS◦ Definition of overheating varies ◦ Cannot provide specific room

temperature guidelines• Dress infants appropriately for the

environment, with no greater than 1 layer more than an adult would wear to be comfortable

• There is currently insufficient evidence to recommend use of a fan as a SIDS risk-reduction strategy

Sleep Clothing

• Alternative to blankets

• Cotton or fleece

Other Recommendations

• Avoid second-hand smoke exposure of the infant; maintain a smoke-free environment

• Do not use apnea monitors as a strategy to prevent SIDS

Benefits of a Safe Sleep Policy

• May save babies’ lives• Shows parents baby’s health and safety

is your #1 priority• Educates staff

◦Consistent care◦Educate parents◦Professional development

• It empowers child care providers• If followed, helps reduce your risk of

liability

Elements of a Safe Sleep Policy• Healthy babies always sleep on their

backs• Obtain physician’s note for non–back

sleepers◦The note should include prescribed sleep position

and reason for not using the back position• Use safety-approved cribs and firm

mattresses• Crib: free of toys, stuffed animals, and

excess bedding◦Alternative: sleep clothing

• Sleep only one baby per crib

Elements of a Safe Sleep Policy

• Room temperature is comfortable for a lightly clothed adult

• Monitor sleeping babies• Have supervised tummy time for awake

babies• Teach staff about safe sleep policy and

practices• Provide parents with safe sleep policy

www.healthychildcare.org/doc/SIDSSamplePolicy.doc

Alternate Sleep Position

• Require written and signed physician’s note

◦Identifies medical reason why baby sleeps in position other than on back

• Inform all child care providers and substitutes

• Keep physician’s note in baby’s medical file and post notice on crib

Partners and Resources

Healthy Child Care America Safe Sleep Resources

American Academy of Pediatrics141 Northwest Point BlvdElk Grove Village, IL 60007-1098◦Phone: 888/227-5409 or 847/434-7951◦Fax: 847/228-7320◦E-mail: childcare@aap.org◦Web site: www.healthychildcare.org

Licensing Requirements

• National Resource Center for Health and Safety in Child Care

– http://nrckids.org – 800/598-KIDS (5437) – Caring for Our Children: National Health and

Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, Third Edition (2011)

– Individual state licensing information

Online Child Care Provider Training Curriculum

• Revised in 2011• Supporting

documents• http://www.healthychil

dcare.org/sids.html

Safe to Sleep campaign

1-800-505-CRIB

http://www.nichd.nih.gov/SIDS/

First Candle

• Provide grief/bereavement services, support services

◦1314 Bedford Ave, Suite 210, Baltimore, MD 21208

◦Phone: 800/221-7437 or 410/653-8226◦Fax: 410/653-8709◦E-mail: info@firstcandle.org◦Web site: www.firstcandle.org

National SUID/SIDS Resource Center

• Provides information about SIDS and other forms of infant death and stillbirth

• Georgetown University• 1-866-866-7437• www.sidscenter.org• info@sidscenter.org

CJ Foundation for SIDS

• 888/8CJ-SIDS (825-7437)• www.cjsids.com

Colorado Child Fatality Prevention System Safe Sleep Page

• Will soon be updated with specific resources for child care provider (including model safe sleep policy)

• http://www.cochildfatalityprevention.com/p/safe-sleep.html

Questions/Discussion