Child Care and Sudden Infant Death Syndrome (SIDS):
A Selected Annotated Bibliography

These articles have been selected by Resource Center staff from PubMed, a service of the National Library of Medicine that includes over 19 million citations from MEDLINE and other life science journals for biomedical articles back to 1948. PubMed includes links to full text articles and other related resources.

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Moon RY, Calabrese T, Aird L.
Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project.
Pediatrics. 2008 Oct;122(4):788-98.

OBJECTIVE: The goal was to evaluate, through an American Academy of Pediatrics demonstration project, the effectiveness of a curriculum and train-the-trainer model in changing child care providers' behaviors regarding safe infant sleep practices. METHODS: Participating licensed child care centers and family child care homes were assigned randomly to intervention and control groups. Observers performed an initial unannounced visit to each site, to watch infants being placed for sleep, to inventory sleep policies, and to administer questionnaires to center staff members. Trainers then used the American Academy of Pediatrics curriculum in educational sessions at intervention sites. Three months later, observers conducted a follow-up observation at each site, and staff members completed a questionnaire about logistic barriers encountered in implementation of safe sleep recommendations. RESULTS: A total of 264 programs and 1212 providers completed the study; the care of 1993 infants was observed. Provider awareness of the American Academy of Pediatrics infant supine sleep position recommendation increased from 59.7% (both groups) to 64.8% (control) and 80.5% (intervention). Exclusive use of the supine position in programs increased from 65.0% to 70.4% (control) and 87.8% (intervention). Observed supine placement increased from 51.0% to 57.1% (control) and 62.1% (intervention). CONCLUSIONS: A sudden infant death syndrome risk reduction curriculum using a train-the-trainer model is effective in improving the knowledge and practices of child care providers. Perceived parental objections, provider skepticism about the benefits of supine positioning, and lack of program policies and training opportunities are important barriers to implementation of safe sleep policies. Continued education of parents, expanded training efforts, and statewide regulations, mandates, and monitoring are critical to ongoing efforts to decrease further the risk of sudden infant death syndrome in child care.

Kiechl-Kohlendorfer U, Moon RY.
Sudden infant death syndrome (SIDS) and child care centres (CCC).
Acta Paediatr. 2008 Jul;97(7):844-5. Epub 2008 May 7.

Our aim was to review the risk of sudden infant death syndrome (SIDS) when infants are in child care (CC), to discuss factors potentially responsible for SIDS in this setting and to describe the impact of previous information campaigns on SIDS in CC. There is a remarkably increased risk of SIDS in CC settings. Special education focussing on a safe sleeping environment has resulted in a decrease of practices known to be associated with SIDS. However, despite a safe sleep environment SIDS prevalence remains disproportionately high. CONCLUSION: Efforts must continue to ensure safe sleeping practices in CC facilities. The possibility of other explanations for the increased prevalence of SIDS in CC settings, such as changes in infant care or stress, must be considered as well.

Markowitz S.
The effectiveness of cigarette regulations in reducing cases of Sudden Infant Death Syndrome.
J Health Econ. 2008 Jan;27(1):106-33. Epub 2007 Apr 8.

Sudden Infant Death Syndrome (SIDS) is a leading cause of mortality among infants and is responsible for thousands of infant deaths every year. Prenatal smoking and postnatal environmental smoke have been identified as strong risk factors for SIDS. Given the link between smoking and SIDS, this paper examines the direct effects of cigarette prices, taxes and clean indoor air laws in explaining changes in the incidence of SIDS over time in the United States. State-level counts of SIDS cases are generated from death certificates for 1973-2003. After controlling for some observed and unobserved confounding factors, the results show that higher cigarette prices and taxes are associated with reductions in SIDS cases. Stronger restrictions on smoking in workplaces, restaurants and child care centers are also effective in reducing SIDS deaths.

Wilson AL, Randall B.
The state of South Dakota's child: 2006--Part II--safe sleep.
S D Med. 2007 Feb;60(2):55-9, 61.

Sudden Infant Death Syndrome (SIDS) has dramatically declined nationally and in South Dakota since the beginning of the "Back to Sleep Campaign" in 1994. Nonetheless, in spite of data showing that the majority of babies now are placed on their backs, data from the US and South Dakota show that racial disparities, the safety of infants' sleep environment, and child care are issues requiring attention as strategies are developed to prevent sudden unexpected infant deaths. Data from the Regional Infant and Child Mortality Review Committee that reviews deaths of infants and children in southeastern South Dakota show that among 37 cases, nearly half of all unexpected deaths of infants between 1997 and 2006 occurred in out-of-home child care settings, considerably higher than what would be expected with census data predictions. Fewer (82%) of the out-of-home deaths, versus in-home deaths (100%), were associated with risks of being put to sleep in a non-supine position or in the presence of other sleeping hazards.

Moon RY, Kotch L, Aird L.
State child care regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign.
Pediatrics. 2006 Jul;118(1):73-83.

BACKGROUND: Despite overall decreases in sudden infant death syndrome deaths and prone sleeping, the proportion of sudden infant death syndrome deaths that occurs in child care settings has remained constant at approximately 20%. In 2003, the American Academy of Pediatrics' Healthy Child Care America program launched its own Back to Sleep campaign to promote the Back to Sleep message for those who care for young children. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of the first 2 years of the Healthy Child Care America-Back to Sleep campaign in improving child care regulations by assessing the inclusion of the elements of a safe sleep environment in the individual state regulations for child care centers and family child care homes. METHODS: We examined regulations available in October 2005 for licensed child care centers and family child care homes in the 50 states and the District of Columbia for specific regulations pertaining to (1) sudden infant death syndrome risk-reduction training for child care providers, (2) infant sleep position, (3) crib safety, (4) bedding safety, (5) smoking, and (6) provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care. RESULTS: Since 2003, when the Healthy Child Care America-Back to Sleep campaign began, 60 of the 101 state regulations for either child care centers or FCCHs have been revised. More than half of these regulations written since 2003 mandate a nonprone sleep position and restrictions on soft bedding in the crib, and the change in these regulations since 2003 is statistically significant. However, of the 101 existing state regulations, only 49 require that infants sleep nonprone, 18 mandate sudden infant death syndrome training for child care providers, 81 have > or = 1 crib safety standard, and 43 restrict soft bedding in the crib. Only 4 regulations require that parents be provided with sleep policy information. CONCLUSIONS: The initial 2 years of the Healthy Child Care America Back to Sleep campaign have been successful in promoting safe infant sleep regulations. Efforts must continue so that safe sleep regulations exist in all jurisdictions.

Moon RY, Sprague BM, Patel KM.
Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001.
Pediatrics. 2005 Oct;116(4):972-7.

OBJECTIVE: A total of 20% of sudden infant death syndrome (SIDS) cases in the 1990s occurred in child care settings. This is much higher than the 8% expected from Census Bureau data. Factors that were associated with child care SIDS included older age; white race; older, more educated mothers; and unaccustomed prone position. Since these findings, much emphasis has been placed on promoting a safe sleep environment in child care. The objectives of this study were to determine the proportion of SIDS occurring in child care in 2001 and to assess risk factors for SIDS in child care. METHODS: We conducted a retrospective review of all SIDS deaths that occurred in 2001 in 13 US states. Information regarding demographics, SIDS risk factors, and child care arrangements were collected and analyzed. Deaths that occurred in child care were compared with deaths that occurred during parental care. RESULTS: Of 480 deaths, 79 (16.5%) occurred in child care settings. Of these child care deaths, 36.7% occurred in family child care homes, 17.7% occurred in child care centers, 21.3% occurred in relative care, and 17.7% occurred with a nanny/babysitter at home. Infants in child care were more likely to be older and to die between the hours of 8 am and 4 pm and less likely to be exposed to secondhand smoke. There was no difference in usual, found, or placed sleep position between child care and home deaths. Approximately one half of the infants who died of SIDS in both settings were found prone, and 20% of deaths in both settings were among infants who were unaccustomed to prone sleep. CONCLUSIONS: The proportion of SIDS deaths in child care has declined slightly but still remains high at 16.5%. Infants in child care are no more likely to be placed or found prone and no more likely to be on an unsafe sleep surface. Educational efforts with child care providers have been effective and should be expanded to unregulated child care providers. In addition, there may be other, yet-unidentified factors in child care that place infants in those settings at higher risk for SIDS.

Nelson EA, Yu LM, Williams S; International Child Care Practices Study Group Members.
International Child Care Practices study: breastfeeding and pacifier use.
J Hum Lact. 2005 Aug;21(3):289-95.

Although the Baby-Friendly Hospital Initiative advises that no pacifiers be given to breastfeeding infants, both breastfeeding and pacifier use may protect against sudden infant death syndrome. The International Child Care Practice Study data set on child care practices associated with sudden infant death syndrome risk from 21 centers in 17 countries was used to describe infant-feeding practices and pacifier use and assess factors associated with breastfeeding. At approximately 3 months of age, rates of breastfeeding only (4%-80%) and pacifier use(12.5%-71%) varied between centers. Pacifier use was negatively associated with breastfeeding, and a dose-response effect was noted. Other negative (multiple birth, smoking by mother) and positive (intention to breastfeed, bed sharing, mothers' education) associations with breastfeeding only were identified. Although causality should not be inferred, these associations are consistent with previous studies. Advice on pacifiers should include potential benefits as well as risks.

de Jonge GA, Lanting CI, Brand R, Ruys JH, Semmekrot BA, van Wouwe JP.
Sudden infant death syndrome in child care settings in the Netherlands.
Arch Dis Child. 2004 May;89(5):427-30.

BACKGROUND: In the Netherlands, there is a very low incidence of sudden infant death syndrome (SIDS) due to effective preventive campaigns. METHODS: During the period September 1996 to August 2002, nationwide 161 deaths from SIDS (about 85% of all cases of SIDS during that time) were investigated by the Cot Death Committee of the Dutch Paediatric Association. RESULTS AND DISCUSSION: Over 10% of cases of SIDS took place during some type of child care. From a national survey carried out in 2000/01 information was available on the child care attendance of 2000 Dutch infants aged 3-6 months. Based on the hours usually spent in child care by these infants, the number of similarly aged infants that died from SIDS while attending child care was 4.2 times higher than expected. Remarkably, the prevalence of known risk factors for SIDS, such as sleeping position and parental smoking, was favourable in the SIDS cases in child care settings. The adherence of child care facilities to the safe sleeping recommendations is high in the Netherlands, and no explanation as to why child care settings may be associated with an increased risk of SIDS is apparent. The possibility of other explanations, such as stress and change in routine care, is hypothesised.

Stubbs-Wynn PE, Krajicek MJ, Hamilton B, Collins S, Torrey V.
SIDS risk-reduction language in state childcare regulations as of July 2002: lessons learned.
J Spec Pediatr Nurs. 2004 Jan-Mar;9(1):32-6.

Daley KC.
Update on sudden infant death syndrome.
Curr Opin Pediatr. 2004 Apr;16(2):227-32.

PURPOSE OF REVIEW: With the introduction of the Back to Sleep campaign by the American Academy of Pediatrics in 1992, the incidence of Sudden infant death syndrome has decreased by almost 50%. Despite this success, SIDS continues to be the most common cause of unexplained infant death in Western countries. This article will briefly review the definition, etiology, and risk factors of SIDS. Attention will then focus on ways to target specific associated risk factors and at risk populations to promote a continued downward trend in the number of SIDS deaths. RECENT FINDINGS: Recent literature in SIDS research has focused on identifying infants at continued risk for SIDS. Children attending child care centers have an increased risk for SIDS, which is of particular concern as the number of infants in child care continues to rise. The reasons for this, along with strategies to decrease this risk, will be reviewed. In addition, the SIDS rate among black infants continues to be more than twice that of white infants. A review of the reasons for this disparity and ways to intervene through targeted campaigns will be discussed. Recent data has also suggested that the prevention of SIDS should not be an indication for use of home cardiorespiratory monitoring. The use of home monitoring may be warranted for some infants and will be reviewed. SUMMARY: Our jobs as pediatricians should be to ensure that the incidence of SIDS continues to decline. This can be done through parent education at each and every well child visit, lobbying to enforce state law to implement SIDS education campaigns for child care centers and within African-American communities, and continued review of the most current literature in SIDS research to keep ourselves current and well informed.

Moon RY, Oden RP.
Back to sleep: can we influence child care providers?
Pediatrics. 2003 Oct;112(4):878-82.

Department of General Pediatrics, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

OBJECTIVE: Despite the fact that 20% of sudden infant death syndrome (SIDS) deaths occur in child care settings, many child care providers continue to be unaware of the association of SIDS and infant sleep position and/or are misinformed as to the risks and benefits of the various sleep positions. The objective of this study was to determine whether an educational program for child care providers regarding SIDS and safe sleep environment is effective in 1) providing basic information and understanding regarding SIDS risk reduction practices, 2) changing child care provider behavior, and 3) promoting development of written sleep position policies. METHODS: We designed a 60-minute educational in-service for child care providers, to be led by a trained health educator. All providers who attended the in-service were asked to complete surveys before and after the in-service. Surveys assessed provider knowledge, beliefs, and practices. A 6-month follow-up interview was conducted with child care centers that had providers participating in the in-service. RESULTS: A total of 96 child care providers attended the educational in-service. Providers who were using the supine position exclusively increased from 44.8% to 78.1%. This change in behavior was sustained, with 85% of centers placing infants exclusively supine 6 months after the intervention. Awareness of the American Academy of Pediatrics recommendation of supine as the preferred position for infants increased from 47.9% to 78.1%, and 67.7% of centers continued to recognize supine as the recommended position 6 months later. The percentage of centers that reported written sleep position policies increased from 18.8% to 44.4%. CONCLUSIONS: A targeted educational in-service for child care providers is effective in increasing awareness and knowledge, changing child care provider behavior, and promoting development of written sleep position policies. This change is sustained over at least a 6-month period.

Moon RY, Weese-Mayer DE, Silvestri JM.
Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies.
Pediatrics. 2003 Apr;111(4 Pt 1):795-9.

Division of General and Community Pediatrics, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org

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.

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October 2009

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