Back to sleep: can we influence child care providers?

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough

OBJECTIVES

Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC.

METHODS

Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed.

RESULTS

Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present.

CONCLUSIONS FOR PRACTICE

Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Social network influences on new mothers' infant sleep adjustments

Despite public awareness campaigns, some parents continue to engage in infant sleep practices that are considered risky by health experts, such as bedsharing or placing their infants on their stomachs. This study examines the role their social networks play in shaping parents' responsiveness to new information and/or suggestions about how they should place their infants for sleep, paying attention to the respective effects of health professionals and their close interpersonal ties. We collected data from a sample of 323 new mothers in Washington, D.C., who described their infant sleep practices and perceived personal social networks. We find evidence that mothers' social networks play a significant role in the likelihood that they adjust their infant sleep practices within the first few months of their infants' lives. Mothers are more likely to change sleep practices when health professionals and/or (lay) family members advise them to do so. The influence of network members is not always positive. For mothers who initially follow safe practices, their probability of change increases if their network members substantially espouse unsafe practices. Among mothers with initially unsafe practices, network members' level of support for safe sleep practices is not predictive of the likelihood of sleep practice change. Implications for potential interventions are discussed.

Field assessment of a safe sleep instrument using smartphone technology

Introduction:

Sudden unexpected infant death is the leading cause of infant mortality with black: white infant mortality remaining at 2:1 for the last decade. Smartphone technology provides a convenient and accessible tool for injury prevention anticipatory guidance among at-risk communities.

Materials and Methods:

A convenience sample of pregnant teen mothers who own a smartphone. During a 1-month postnatal home visit, a safe sleep environment survey was administered, infant sleep practices were observed, and mothers trained to take and submit standard infants’ sleep environment photographs. Photographs were independently assessed for inter-rater reliability (IRR) across five sleep safety domains (primary outcome): sleep location, surface, position, presence of soft items, and hazards near the sleep area. Expert and novice coders IRR was measured using Cohen’s kappa coefficient (K). Sleep safety correlation between photographs and observation, and parent report and observation was determined.

Results:

Sixteen (57.1%) mothers completed the home visit. Most parents reported infants sleeping supine (78.5) in parents’ bedroom (85.9%). Photographs demonstrated sleep position, soft items without the baby present, and hanging toys had perfect agreement across all three coder pairs. Safe sleep experts’ IRR demonstrated perfect agreement for sleep location, position, and soft items. While 83.8% of parents were observed putting their infants down to sleep on their back, 78.5% of parents reported doing the same and 82.4% of the photographs demonstrated supine infant sleep position.

Conclusion:

Using photographs, coders can reliably categorize some key infant sleep safety aspects, and photograph sleep safety is comparable to parent report and direct observation.

Integrative literature review: sleep patterns in infants attending nurseries

OBJECTIVE

To identify evidence available in the literature about sleep patterns of infants attending nurseries.

METHOD

An integrative review of studies published in Portuguese, English or Spanish available in full text on LILACS, CINAHL, and PubMed databases. The following descriptors sono, lactente and creches or berçários (in Portuguese) and sleep, infant and childcare or nurseries were used for LILACS, CINAHL and Pubmed, respectively. Nine studies were selected and analyzed.

RESULTS

The main component explored in the studies about sleep pattern is the sleep position of the infants, due to its association with sudden infant death syndrome. The results pointed to the need to promote and develop written guidelines regarding behavioral practices to reduce the risk of this phenomenon.

CONCLUSION

Evidence has identified sleep issues, mainly regarding the sleep position of the infant and the environment where the infant sleeps, showing that it is critical to set routines and interventions to improve the quality of sleep care of infants attending nurseries.

Sudden infant death syndrome: Knowledge and practise in parents of preterm infants

BACKGROUND

Preterm infants are at higher risk of sudden infant death syndrome (SIDS) compared with term born infants and the risk is inversely proportional to the gestational age and birthweight. Parents of these infants should have adequate knowledge and practise the recommended SIDS risk reduction measures.

METHODS

A survey was conducted between December 2016 and August 2017 at Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur. Parents of preterm infants ≤36 weeks' gestation were invited to answer a self-administered questionnaire to assess their knowledge and practise regarding SIDS risk reduction.

RESULTS

Forty-nine (61.33%) of the 80 parents had heard of SIDS prior to the interview, with social media being the commonest source of information (67.3%). Only 35 (43.7%) correctly answered at least five of nine questions on knowledge of SIDS risk reduction ("good knowledge"). When compared with the group of parents who answered less than five questions correctly ("poor knowledge"), there was no significant difference in the demographic and infant characteristics between the groups. The majority (68.8%) of parents practised bed sharing with their infants, and this was significantly more common in the group of parents with poor knowledge (P = 0.01). Household smoking was also significantly more common in the group of parents with poor knowledge (P = 0.048).

CONCLUSION

Knowledge on SIDS risk reduction measures was generally poor among parents of preterm infants in this study. Cigarette smoking, bed sharing and non-supine sleep positions, which are associated with increased risk of SIDS, were common practise among the present subjects.

Child Care Health Consultation Improves Infant and Toddler Care

INTRODUCTION

Many families enroll their infants and toddlers in early education and child care programs. The Pennsylvania Chapter of the American Academy of Pediatrics recruited 32 child care centers that care for infants and toddlers to be linked with a child care health consultant (CCHC).

METHOD

Project staff assigned the centers alternately to an immediate intervention or a 1-year delayed intervention (contrast) group. At entry into the project, and then 1 and 2 years later, an evaluator assessed center compliance with 13 standards for infants and toddler care selected from Caring for Our Children: National Health and Safety Performance Standards (3rd ed.). Project staff linked the Immediate Intervention centers with a CCHC in Year 1. In Year 2, in a crossover comparison, project staff linked Contrast centers with a CCHC.

RESULTS

Working with a CCHC effectively improved compliance with some selected health and safety standards.

Impact of a Randomized Controlled Trial to Reduce Bedsharing on Breastfeeding Rates and Duration for African-American Infants

Bedsharing is associated with both increased breastfeeding and increased risk of sudden and unexpected infant deaths. The objective was to determine impact of sleep location and counseling about sleep location on breastfeeding exclusivity and duration in African-Americans. 1194 mothers of newborns were randomized to receive messaging emphasizing either safe sleep practices to reduce SIDS risk or safe sleep practices to prevent SIDS/suffocation. Mothers completed four interviews in the 6 months after delivery. The most common sleep arrangement was roomsharing without bedsharing ("roomsharing"). Duration of any breastfeeding was 6.1 and 5.3 weeks for infants who usually bedshared or roomshared, respectively (p = 0.01). Duration of exclusive breastfeeding was 3.0 and 1.6 weeks for infants who usually bedshared or roomshared, respectively (p < 0.001). Group assignment did not affect breastfeeding duration. The most common sleep arrangement for African-American infants <6 months was roomsharing. An intervention designed to discourage bedsharing did not impact breastfeeding duration.

Paediatricians' Practice About SUDDEN Infant Death Syndrome in Catalonia, Spain

Background SIDS is the major cause of death among healthy born infants in developed countries. Its causes are still unclear, but its risk can be reduced by implementing some simple active interventions. In Spain, limited attention was given to SIDS by the national healthcare system, and actual data on healthcare professionals' practice on this topic was not available. This study explored for the first time paediatricians' knowledge and practice about SIDS. Methods A cross-sectional survey was carried out between November 2012 and April 2013 in Catalonia, and reached 1202 paediatricians. The response rate was 46%. Results 94% of respondents perceived themselves as qualified for giving advice and recommendations about SIDS to parents, but only 58% recognized the supine position as the safest position and recommended the supine position exclusively to parents. Seniority and 'having received a specific training about SIDS' were detrimental to paediatricians' knowledge. Discussion Efforts should be made in order to improve paediatricians' knowledge and practice about SIDS. Specific refresher trainings are highly recommended, and should especially target paediatricians with higher seniority. These trainings could be provided as optional modules, as we could see that the paediatricians who would most benefit from them are already aware of the need to refresh their knowledge.

SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment

Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.

Messaging Affects the Behavior of African American Parents with Regards to Soft Bedding in the Infant Sleep Environment: A Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of specific health messages on the decisions of African American parents regarding soft bedding use, specifically related to the high degree of self-efficacy that African American parents have with regards to preventing infant suffocation vs low self-efficacy with regards to sudden infant death syndrome (SIDS) risk reduction.

STUDY DESIGN

We conducted a randomized, controlled clinical trial of African American mothers of infants. The control group received standard messaging emphasizing safe sleep practices recommended by the American Academy of Pediatrics for the purposes of SIDS risk reduction. The intervention group received enhanced messaging emphasizing safe sleep practices for both SIDS risk reduction and suffocation prevention. Participants completed interviews at 2-3 weeks, 2-3 months, and 5-6 months after the infant's birth.

RESULTS

Of 1194 mothers enrolled, 637 completed all interviews. The use of soft bedding both in the past week and last night declined with age (P < .001). Infants in the enhanced group had a lower rate of use of soft bedding in the past week (P = .006) and last night (P = .013). Mothers who received the enhanced message were more likely to state that they avoided soft bedding to protect their infant from suffocation.

CONCLUSIONS

African American mothers who receive an enhanced message about SIDS risk reduction and suffocation prevention are less likely to use soft bedding in their infant's sleep environment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01361880.

Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change?

Sudden infant death syndrome (SIDS) and other sleep-related infant deaths, such as accidental suffocation and strangulation in bed and ill-defined deaths, account for >4000 deaths annually in the USA. Evidence-based recommendations for reducing the risk of sleep-related deaths have been published, but some caregivers resist adoption of these recommendations. Multiple interventions to change infant sleep-related practices of parents and professionals have been implemented. In this review, we will discuss illustrative examples of safe infant sleep interventions and evidence of their effectiveness. Facilitators of and barriers to change, as well as the limitations of the data currently available for these interventions, will be considered.

An analysis of attitude toward infant sleep safety and SIDS risk reduction behavior among caregivers of newborns and infants

OBJECTIVE

To explore beliefs and attitude toward infant sleep safety and sudden infant death syndrome (SIDS) risk reduction behaviors among caregivers of newborns and infants.

STUDY DESIGN

A convenience sample comprised of 121 caregivers of newborns at Staten Island University Hospital completed a questionnaire.

RESULTS

Despite an overall favorable attitude toward safe sleep practices, a majority disagreed with use of pacifiers (53%) and believed that swaddling (62%) as well as the use of home monitors (59%) are acceptable practices. The caregivers who recalled being taught about safe sleep had higher perception of infant vulnerability (P<0.001), more confidence in their ability to implement safe sleep behaviors (P<0.0006) and stronger belief that safe sleep behaviors are effective (P<0.01).

CONCLUSION

Active caregiver education may result in more effective demonstration of safe sleep and SIDS risk reduction behaviors. Further study is needed to assess if favorable attitudes toward safe sleep practices correlate with actual demonstrated behaviors.

Infant Mortality and SIDS Perceptions Among Key Healthcare Professional Informants in Sedgwick County, KS

INTRODUCTION

Sedgwick County, KS, has one of the highest infant mortality rates (IMR) in the USA, of which sudden infant death syndrome (SIDS) is a large component. The purpose of this study was to assess local key informants' awareness of the high IMR overall, their knowledge and beliefs about SIDS risk factors specifically, and their recommendations for ways to increase physician and community awareness of SIDS within Sedgwick County, KS.

METHODS

Structured interviews were conducted with key informants from Sedgwick County, KS.

RESULTS

Four themes emerged from key informant interviews: low level of awareness of infant mortality and SIDS, target population most at risk for SIDS/infant mortality, and barriers to and importance of SIDS education. Key informants were in consensus that there was a lack of general community awareness surrounding the high IMR in Sedgwick County. Strategies were identified to address this issue, including consistent SIDS education of medical providers and parents, social support to moms, use of social media, and involving the faith community in educating target populations about risk factors.

CONCLUSIONS

Health and public health key informants provided an overall view of their perception of the SIDS problem in Sedgwick County, KS. Based on collected interviews, the consensus was there are significant problems within Sedgwick County around the issue of SIDS awareness (severity of the problem), SIDS risk, and barriers to increasing SIDS education among professional and community members. African-Americans were identified as the population with the highest infant mortality and SIDS rates in Sedgwick County by health and public health key informant participants. A concerted, educational approach was recommended as the best way forward to reduce SIDS risk within this community.

Using a pacifier to decrease sudden infant death syndrome: an emergency department educational intervention

Background. Pacifier use decreases the risk of sudden infant death syndrome (SIDS). An emergency department (ED) visit may provide an opportunistic ‘teachable moment’ for parents.

Objectives. To test the hypotheses (1) that caregivers were less familiar with the role of pacifiers in sudden infant death (SIDS) prevention than other recommendations, and (2) that an ED educational intervention would increase pacifier use in infants younger than six months, and (3) that otitis media would not occur more frequently in pacifier users.

Methods. We did an intervention-group-only longitudinal study in a county hospital ED. We measured pacifier use infants and baseline knowledge of SIDs prevention recommendations in caregivers. We followed up three months later to determine pacifier use, and 12 months later to determine episodes of otitis media.

Results. We analyzed data for 780 infants. Parents knew of advice against co-sleeping in 469/780 (60%), smoking in 660/776 (85%), and prone sleeping in 613/780 (79%). Only 268/777 (35%) knew the recommendation to offer a pacifier at bedtime. At enrollment 449/780 (58%) did not use a pacifier. Of 210/338 infants aged less than 6 months followed up 41/112 (37%) non-users had started using a pacifier at bedtime (NNT 3). Over the same period, 37/98 (38%) users had discontinued their pacifier. Otitis media did not differ between users and non-users at 12 months.

Conclusion. Caregiver knowledge of the role of pacifiers in SIDS prevention was less than for other recommendations. Our educational intervention appeared to increase pacifier use. Pacifier use was not associated with increased otitis media.

SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment

Despite a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed for sleep in a nonprone position, this decline has plateaued in recent years. Concurrently, other causes of sudden unexpected infant death occurring during sleep (sleep-related deaths), including suffocation, asphyxia, and entrapment, and ill-defined or unspecified causes of death have increased in incidence, particularly since the AAP published its last statement on SIDS in 2005. It has become increasingly important to address these other causes of sleep-related infant death. Many of the modifiable and nonmodifiable risk factors for SIDS and suffocation are strikingly similar. The AAP, therefore, is expanding its recommendations from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. The recommendations described in this report include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunization, consideration of a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. The rationale for these recommendations is discussed in detail in this technical report. The recommendations are published in the accompanying "Policy Statement--Sudden Infant Death Syndrome and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment," which is included in this issue (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2220).

The physician's role in reducing SIDS

Despite a sustained public education campaign aimed at reducing the risks of sudden infant death syndrome (SIDS), it remains one of the leading causes of infant death. This study aims to determine physicians' knowledge of SIDS and whether physicians are discussing how to reduce the risk of SIDS with parents. A cross-sectional survey is sent to 912 pediatricians, family practitioners, and obstetrician-gynecologists in Central New York State. The response rate is 23.5%. Almost all respondents (99.5%) agree that certain measures can be taken to reduce the risks of SIDS, but 30.3% incorrectly state that the safest sleep position is something other than on the back. Although 97.6% agree that it is important to discuss SIDS with parents, 30% admit to not discussing this information. To continue to decrease the SIDS rate, physicians must take responsibility for educating themselves and parents about safe sleep practices and other SIDS risk factors.

Child health in child care: a multi-state survey of Head Start and non-Head Start child care directors

INTRODUCTION

Directors of Head Start (HS) and non-Head Start (non-HS) child care centers were surveyed to compare health consultation and screening for and prevalence of health risks among enrolled children.

METHODS

Directors of licensed centers from five states were surveyed from 2004 to 2005. Data were analyzed using cross-tabulation and logistic regression techniques.

RESULTS

A total of 2753 surveys were completed. HS centers were more likely than non-HS centers to consult health professionals (P < .0001). More than 90% of HS centers screened for health problems compared with 64.9% of non-HS centers (P < .0001). Almost all HS centers provided parents with child health information. Children at HS centers were at high risk for dental problems. Less than 3% of HS center directors, versus 11.3% of non-HS directors (P < .0002), reported TV viewing for more than an hour a day.

DISCUSSION

Children in HS centers were more likely to receive health consultations and screenings, were at higher risk for dental problems, and watched less TV compared with children in non-HS centers. HS centers promoted health significantly more frequently than did non-HS centers.

Family child care providers' experience in health promotion

Family child care providers may be well-suited to provide health promotion to young children and their families. The investigators conducted a qualitative study using in-depth interviews with family child care providers serving low-income children. Child care providers perceive that they have an important role in health promotion, including (1) the child's physical health, (2) the child's development, and (3) supporting and educating parents, and are willing to assume this role in the context of collaborative relationships with parents. Providing education and ongoing support to child care providers in developing collaborative partnerships may enhance opportunities for health promotion in this setting.

Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project

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.

Factors associated with ambulance requests for febrile seizures

The objective of this study was to determine factors associated with ambulance requests for febrile seizures. This study retrospectively investigated medical records of patients who visited the Emergency Care Unit at Tokyo Metropolitan Toshima Hospital in the 5-year period after April 2001. Subjects' basic characteristics (e.g., age and sex), medical history of febrile seizures, sibling and parental medical history of febrile seizures, and distance from hospital were investigated. In total, 310 subjects used ambulances, and 106 came to the hospital without requesting ambulances. The results of binomial logistic analysis indicated that factors associated with ambulance requests included patient's and parents' medical history of febrile seizures. Increasing awareness of febrile seizures and provision of a general public educational campaign are possible strategies to help decrease unnecessary ambulance requests. However, a medical history of febrile seizures among siblings revealed no association, indicating the need to conduct repeated early-stage interventions.

Sudden infant death syndrome (SIDS) and child care centres (CCC)

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.

State child care regulations regarding infant sleep environment since the Healthy Child Care America-Back to Sleep campaign

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.

Barriers to Following the Back-to-Sleep Recommendations: Insights From Focus Groups With Inner-City Caregivers

BACKGROUND

African American infants have a higher incidence of SIDS and increased risk of being placed in the prone position for sleep.

OBJECTIVE

To determine new barriers and more information about previously identified barriers that interfere with adherence to the Back-to-Sleep recommendations among inner-city, primarily African Americans.

DESIGN/METHODS

We conducted 9 focus groups with caregivers of infants and young children from women, infants, and children centers and clinics in New Haven and Boston. Themes were identified using standard qualitative techniques.

RESULTS

Forty-nine caregivers participated, of whom 86% were African American, 6% were Hispanic, 4% were white, and 4% were other. Four themes were identified: 1) SAFETY: Participants chose the position for their infants based on which position they believed to be the safest. Some participants did not choose to put their infants in the supine position for sleep because they feared their infants would choke; 2) Advice: Participants relied on the advice of more experienced female family members. Health care providers were not uniformly a trusted source of advice; 3) Comfort: Participants made choices about their infants sleeping positions based on their perceptions of whether the infants appeared comfortable. Participants thought that their infants appeared more comfortable in the prone position; 4) Knowledge: Some participants had either limited or erroneous knowledge about the Back-to-Sleep recommendations.

CONCLUSIONS

We identified multiple barriers to adherence to recommendations regarding infant sleep position. Data obtained from these focus groups could be used to design educational interventions aimed at improving communication about and adherence to the Back-to-Sleep recommendations.

Opportunities for health promotion education in child care

OBJECTIVES

Comprehensive health promotion education is not feasible through pediatric office visits alone. Opportunities may exist for enhanced health promotion in child care settings. The objectives of this study were to understand the attitudes toward, barriers to, and strategies for incorporating health promotion activities in child care settings as well as topics that are deemed most useful from the perspectives of parents, child care directors, and health consultants. We also sought to understand the health consultants' (health professionals serving as consultants to child care centers) current and desired roles in leading health promotion activities in child care settings.

METHODS

We conducted simultaneous surveys of all licensed child care center directors and their health consultants in Boston. A total of 240 parents in 16 randomly selected centers were also surveyed.

RESULTS

A total of 97 (65%) directors in the 150 child care centers identified responded. A total of 71% (56 of 79) of consultants and 58% (138 of 240) of parents responded. Parents (89%), child care directors (88%), and health consultants (80%) believe that health promotion activities through child care centers would improve the health knowledge and behaviors of preschool children. A total of 45% of parents reported already receiving useful health information from child care staff and materials distributed in child care. Most topic areas that were suggested to parents were considered useful, with the greatest utility in the areas of behavior/discipline, child development, and emergency management. No significant barriers were identified by health professionals. Lack of funds (63%) and lack of someone to provide information (59%) were the top barriers identified by directors. An educational session on health topics by health care professionals was believed to be the best strategy to improve health promotion education for families. Among the health consultants, 83% of nurses or nurse practitioners said that they would be able to provide health education in child care compared with 53% of physicians.

CONCLUSION

Parents, child care center directors, and health professionals believe that enhancing health promotion education in child care could improve child health. Collaboration between pediatricians and early care and education professionals has the potential to improve the breadth and effectiveness of health promotion education. Effective strategies are necessary to optimize access to health professionals by early educators, and effectively utilize the unique skills and preferences of physicians and nurses to promote health education in child care.

Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001

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.

Update on sudden infant death syndrome

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.