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Reducing the Risk of SIDS in Child Care
- 1. Presented by: Massachusetts Department of Early Education and Care Developed in Collaboration with: Associated Early Education and Care Child Development and Education, Inc. MA SIDS Center MA Department of Public Health REDUCING THE RISK OFREDUCING THE RISK OF SIDS IN CHILD CARESIDS IN CHILD CARE Revised February, 2012
- 2. 2 Reduce the risk of infants dying of SIDS in child care settings. INTENDED OUTCOME OF THIS TRAINING
- 3. 3 Define SIDS Address misconceptions about SIDS deaths Discuss Risk Factors associated with SIDS Design a Safe Sleep Policy Discuss and provide safe sleep information to parents Follow appropriate procedures should an infant death occur in the program Identify and access SIDS-related resources LEARNINGLEARNING OBJECTIVESOBJECTIVES
- 4. 4 The sudden death of an infant under one year of age when the cause of death remains unexplained after: • Death scene investigation and autopsy • Review of baby’s medical history WHAT IS SUDDEN INFANTWHAT IS SUDDEN INFANT DEATH SYNDROME?DEATH SYNDROME?
- 5. • 4500 infants die of no obvious cause in the U.S. annually • Of these, 50% are due to SIDS • SIDS is the leading cause of death for infants between 1 and 12 months of age • SIDS rates have declined by more than 53% since 1990 • Deaths in child care* in US accounted for 20% in 1996 and 16.5% in 2001 (Moon, et.al., Pediatrics, 2000 and 2005) • The exact cause of SIDS remains unknown • Experts cannot predict which babies will die from SIDS * child cared for by a non-parental caregiver. SIDS FACTSSIDS FACTS Massachusetts SIDS Center 5
- 6. 6 SIDS RISK FACTORSSIDS RISK FACTORS • Babies who sleep prone (lying face downward) • Babies who sleep on their sides • Unaccustomed tummy sleepers • Smoking during pregnancy • Exposure to 2nd hand smoke • American Indian and African American babies • Multiple Births • Males slightly more than females • Young Maternal Age (under 20) • Mothers with late or no prenatal care • Preterm (before 37 weeks) and birth weight under 5.5 lbs. • Bed sharing • Mild upper respiratory infections • Soft sleep surfaces • Cluttered sleep area • Overheating: temperature range should be 68°-72° • Substance abuse during pregnancy Massachusetts SIDS Center
- 7. What is Bed Sharing? Bed Sharing refers to a sleeping environment in which the baby shares the same sleeping surface with another person. What is Co-Sleeping? Co-Sleeping refers to a sleeping environment in which the baby shares the same room with a parent/caregiver. BED SHARINGBED SHARING Infants who share a bed with another person, adult or child, are at an increased risk for SIDS. 7
- 8. 8 SIDS Critical development period External stressors (Sleep position and sleep environment) Vulnerable infant TRIPLE RISK MODELTRIPLE RISK MODEL
- 9. 9 • Two thirds of US infants younger than 1 year are in non-parental child care. • Infants of employed mothers spend an average of 22 hours per week in child care. • Statistically, we would expect less than 9% of SIDS deaths to occur in child care. Ehrle et al, 2001 Infants in Child Care Massachusetts SIDS Center SIDS AND CHILDSIDS AND CHILD CARECARE
- 10. 10 SIDS IN CHILD CARESIDS IN CHILD CARE Although we would expect less than 9% of SIDS deaths to occur in child care settings; • In the United States, 16.5% of SIDS deaths occurred while the infant was in the care of a non- parental caregiver. – 36.7% in family child care – 17.7% in child care centers – 21.3% in relative care – 17.7% with nanny/babysitter at home » Moon & al. 2005
- 11. 11 Number of SIDS Deaths in Massachusetts 1990 - 2001 0 10 20 30 40 50 60 70 80 90 100 90 91 92 93 94 95 96 97 98 99 '00 '01 Total number of SIDS Deaths SIDS Deaths in child care Chart: Massachusetts SIDS Center
- 12. 12 • Place baby on back to sleep • Use firm surface • Keep soft objects and loose bedding out of sleep area/crib • Avoid overheating • Supervise infants during sleep • Place one infant at a time in each crib / playpen / bassinet for sleep. • Do not smoke around infants • Consider a pacifier at nap and bedtime during 1st year (with parental approval) • Continue to educate others about SIDS and safe sleep practices Massachusetts SIDS Center REDUCING THE RISK OFREDUCING THE RISK OF SIDSSIDS
- 13. 13 1. Back to Sleep 2. Avoid Overheating 3. Safe sleep environment and supervision 4. “Tummy Time” when infant is awake and supervised SIDS RISK REDUCTIONSIDS RISK REDUCTION
- 14. SIDS RISK REDUCTION:SIDS RISK REDUCTION: BACK TO SLEEP 14
- 15. 15 Why don’t people put babies to sleep on their backs? EXAMINING COMMON BELIEFSEXAMINING COMMON BELIEFS
- 16. • The baby may spit up / choke
- 17. • The baby will get a bald spot
- 18. • The baby will get a flat head Before After
- 19. • The baby won’t sleep as soundly
- 20. – Check baby upon arrival at program. If baby is in car seat, remove and place in crib – Never cover baby’s head with a blanket – Room temperature should be between 68°-72° – Do not overdress baby or leave in winter clothes while inside or during extended rides in a car seat SIDS RISK REDUCTIONSIDS RISK REDUCTION AVOID OVERHEATINGAVOID OVERHEATING
- 21. 21 SIDS RISK REDUCTIONSIDS RISK REDUCTION A SAFE SLEEP ENVIRONMENT ANDA SAFE SLEEP ENVIRONMENT AND SUPERVISIONSUPERVISION • Safe crib • No blankets • No pillows • No toys • No wedges • No smoke
- 22. Safe sleep environment whileSafe sleep environment while transporting?transporting? 22
- 23. 23 SIDS RISK REDUCTIONSIDS RISK REDUCTION TUMMY TIMETUMMY TIME
- 24. 24 SIDS RISK REDUCTIONSIDS RISK REDUCTION Communicate with ParentsCommunicate with Parents
- 25. 25 • Have a plan in place • Review the plan with all staff periodically • Practice emergency response • Be trained in infant first aid and CPR HANDLING A MEDICALHANDLING A MEDICAL EMERGENCYEMERGENCY
- 26. 26 • Initiate one sequence of CPR • Call 911 • Return to CPR • Call emergency child care backup person • Send/bring infant’s medical records to hospital • Accompany infant to hospital, if possible • Notify parents • Notify supervisor if you have one or child care system • Notify EEC FIRST AID:FIRST AID: UNRESPONSIVE INFANTUNRESPONSIVE INFANT
- 27. This presentation was adapted from Reducing the Risk of SIDS Designed by: The American Academy of Pediatrics: 2004, revision 4/05 with assistance from: Mary McClain, RN, MS Massachusetts SIDS Center Revised 2/12 THANK YOU
- 28. Supplemental Handouts: •Questionnaire •Additional Resources •Certificate of Completion Right click on the link below, then choose “open hyperlink” to access important documents.
Editor's Notes
- Talking about the death of a child is difficult under any circumstances. If you have experienced the death of a child – either your own, or someone you cared for – you may want to complete this training when you have a support person available to talk to. If you need to take a break and come back to the training later, you can do that. Just be sure to print out the questions at the end of the training and keep them on file for your licensor’s review.
- Child care providers perform an essential service in our society. More parents are enrolling infants in early education and child care programs. Child care providers need to have the most up-to-date information concerning the care of infants. This training will inform you about SIDS. Although we can not yet prevent all SIDS deaths, using the information from this training will reduce the RISK of SIDS deaths that occur in child care settings.
- At the conclusion of this training, you should be able to:
- The definition we use for SIDS is taken from an article in Pediatric Pathology by Willinger, James, and Catz . SIDS is sudden death of an infant under 1 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. SIDS is a diagnosis of exclusion. This means that all other possible causes of death are ruled out before a SIDS diagnosis is applied. A SIDS diagnosis takes into account autopsy findings, results of the investigation of the place where the baby died, and a review of the baby’s medical history. Sometimes the family’s health history also is reviewed. Unfortunately, experts are not able to predict which babies will die from SIDS. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677–684
- These SIDS facts are based on years of national data that show which, when, where, at what age, and under what circumstance babies die suddenly and unexpectedly. The data are derived from researchers at the National Institute of Child Health and Human Development. SIDS is The cause of death for approximately 2,250 babies in the US (in 2000). The leading cause of infant death between 1 and 12 months of age. More prevalent in male babies than female babies. Since the American Academy of Pediatrics recommended Back Sleeping in 1992, and following the launch of the “Back to Sleep” Campaign in 1994, the percentage of babies placed on their backs for sleep has increased dramatically; and the rate of SIDS death has declined by half.
- Research indicates that some infants are at a higher risk of SIDS because of certain risk factors, which are listed on this slide. Babies who usually sleep on their backs and then are placed on their tummies to sleep are 18 – 20 times more likely to die of SIDS than babies who sleep on their backs. Babies who sleep on their tummies all the time are almost 7 times more likely to die of SIDS than babies who sleep on their backs; and babies who sleep on their sides are twice as likely die of SIDS than babies who sleep on their backs. Smoking during pregnancy triples the risk of SIDS; Exposure to second hand smoke doubles the risk. Aboriginal/ American Indian babies are between 3 and 10 times more likely to die of SIDS than are caucasian babies, and African American babies are twice as likely as caucasian babies to die of SIDS. Babies from multiple births (twins, triplets, etc) , males, babies born to mothers younger than 20 or with late or no prenatal care; preterm and low birth-weight babies, babies who share a bed, have a mild upper respiratory infection (cold), sleep on soft surfaces, or are overheated are all at increased risk of SIDS.
- Bed sharing means sharing a bed, and increases the risk of SIDS. Co-sleeping is sharing a room (but not a bed), and does not increase the risk of SIDS.
- Researchers believe that no single risk factor is likely to cause a SIDS-related death. Rather, the coming together of several risk factors may contribute to what causes an infant to die from SIDS. The triple risk theory takes into account the following 3 factors: The critical development period coincides with a period of rapid growth and development of the brain during the first 6 months of life. 90% of all SIDS deaths occur during this period. As caregivers, we cannot influence this developmental timeline. The vulnerable infant is one with an intrinsic developmental defect that is undetectable. As caregivers, we cannot influence these pre-birth factors, although parents may be able to do so by not smoking during pregnancy, seeking regularly and timely pre-natal care, and not exposing the growing fetus to drugs or other potential toxins. The third area is external stressors (such as separation from parents and the first day in a new child care program) and environmental factors such as sleeping on the stomach, loose bedding, inappropriate sleep surfaces (eg, couches, water beds), or smoking in the baby’s environment. These are the circumstances that caregivers can change. Throughout this presentation, we will be discussing how we can limit the external stressors during this important developmental period. Guntheroth WG, Spiers PS. The triple risk hypotheses in sudden infant death syndrome. Pediatrics. 2002;110:e64
- Two thirds of US infants spend at least some time in child care. Infants spend an average of 22 hours per week in child care. If you assume that SIDS occurs equally around the clock, you can determine that approximately 8.8% of SIDS deaths are likely to happen in child care. (67% of all infants are in child care) x (22 hours/week spent in child care) / (168 total hours/week) = 8.8% of SIDS deaths should occur in child care. Ehrle J, Adams G, Tout K. Who’s Caring for Our Youngest Children? Child Care Patterns of Infants and Toddlers. Washington, DC: The Urban Institute; 2001
- Unfortunately, the actual rate of SIDS deaths in child care is almost double what would statistically be expected. That is why we are focusing on reducing the risk of SIDs deaths in child care settings.
- The red line on this chart illustrates the decline in SIDS Deaths between 1990 and 2001. The American Academy of Pediatrics first recommended back sleeping in 1992, and began the “Back to Sleep” campaign in 1994. Since that time there has been a dramatic increase in back sleeping of infants, and a 50% decrease in SIDS deaths (nationwide). While we cannot impact the critical development period or the intrinsic risk factors that a baby is born with, you can change the environmental factors in an infant’s child care environment. YOU CAN MAKE A DIFFERENCE!
- Many of these strategies are required by EEC’s licensing regulations, for example: placing the baby on his/her back to sleep; using a firm surface for sleeping; keeping soft objects and loose bedding out of the sleep area; avoiding overheating; supervising infants during sleep, including direct visual supervision of an infant younger than six months during the first six weeks in care; placing only one infant at a time in a crib, playpen or bassinet for sleep; and not smoking around infants. The AAP now advises that using a pacifier at nap time decreases the risk of SIDS. For breastfed babies, a pacifier should only be offered after breastfeeding is firmly established.
- SIDS risk reduction can be implemented in child care facilities or in the baby’s own home by incorporating the following 4 major strategies. Let’s look at each of these strategies in more detail.
- The first and perhaps most important strategy to reduce SIDS is placing the baby on his/her back to sleep….naptime, nighttime, EVERYTIME. Once a child is old enough to roll over on his/her own, you do not need to reposition him while sleeping. Do not use car seats, swings, high chairs and bouncy chairs as places to nap a baby.
- This seems like such a simple thing to do. So, why aren’t all babies placed on their backs for sleep?
- Some folks think that placing the baby on his back will increase the risk that the baby will choke if she spits up. In fact, the opposite is true. When lying on her back, the trachea (windpipe) is above or on top of the esophagus (food tube). Food coming from the esophagus would have to go against gravity to cause choking while in this position. Babies are actually less likely to aspirate or choke when lying on their backs.
- Some parents are concerned that the baby will develop a bald spot on the back of her head. While it is true that babies who sleep on their backs sometimes do develop bald spots, these bald spots are temporary! As the baby grows, begins to sit up, and become more mobile, the hair on the back of the baby’s head will grow back. A temporary bald spot is a small price to pay to avoid the risk of SIDS.
- Parents are sometimes concerned that sleeping on his back will cause the baby to have a flat head. Sometimes newborns have a flat or misshapen head as a result of the pressures on their soft skull during birth. However, back sleeping can contribute to a flattening of the skull. In most cases this flattening will correct itself as the baby spends less time flat on his back, becomes mobile and sits up more. You can minimize this effect with the following strategies. 1. Alternate in which end of the crib you place the baby’s feet. This will cause her to naturally turn toward light or objects in different positions, which will lessen the pressure on one particular spot on her head. 2. Vary the baby’s position when she is awake. Spend time holding the baby in your arms as well as watching her play on the floor, both on her tummy and on her back. Alternate the baby’s position when you feed her a bottle, and avoid putting her for long periods in car seats, swings, bouncers or other equipment that cause friction on the back of the head. This helps to minimize the development of bald spots as well.
- It is true that some infants who lie on their backs do not sleep as deeply as those who lie on their stomachs. Some infants who are placed on their backs may be fussy or cry. However, the absence of very deep sleep is believed to help protect infants against SIDS. Babies who are placed on their stomachs sleep more deeply, are less reactive to noise, experience less movement, and are less able to be aroused than back sleeping infants. These characteristics are likely to put an infant at higher risk of SIDS. So, even though comfort is important, the infant's safety is more important; the back sleep position should be used even if the infant seems to sleep less comfortably.
- A second strategy to minimize SIDS risk is to avoid overheating the baby. At an early age, babies are unable to regulate their own body temperature. Over time their ability to regulate body temperature and other internal comfort controls increases. Signs that the baby is too hot include sweating, damp hair, flushed cheeks, heat rash, and breathing rapidly. A good rule of thumb is to dress the baby the way you would like to be dressed to sleep. Babies should not be overheated at any time, but particularly not when sleeping – either in their cribs or in car seats.
- A third strategy to reduce the risk of SIDS is to ensure a safe sleep environment and adequate supervision. The safest place for a sleeping baby is on his or her back in a safety-approved crib that is free of excess bedding and stuffed animals. The baby should sleep in a smoke-free environment. The crib should be safety approved with slats spaced not more than 23/8" apart. The firm mattress should be a snug fit for the crib, portable crib, or playpen frame. The space between the mattress edge and crib frame should not be more than the width of 2 adult-sized fingers, and the mattress should have a tight-fitting sheet. It is best practice to not put babies to sleep anywhere but in a safety-approved crib. Chairs, sofas, water beds, cushions, and standard or adult beds are NOT safe sleep surfaces because babies can fall or become entrapped in crevices in the furniture or between cushions, and because they do not provide a firm sleep surface. The crib should not contain excess bedding, comforters, or pillows. Excess bedding and fluffy blankets, comforters, and pillows can impair the baby’s ability to breathe if these items cover the face. Toys and stuffed animals as well as bumper pads and wedges should not be placed in the crib. The crib should be placed in a smoke-free environment.
- A fourth strategy to reduce the risk of SIDS is “Tummy Time”. Being placed on their tummies while awake and supervised allows babies the opportunity to develop strong muscles for crawling, rolling over (which helps reduce the risk for SIDS) and other movements. Babies should have tummy time right from their first day of life. You should interact with the baby during tummy time for a short period 2 to 3 times each day, increasing the amount of time as the baby shows enjoyment of the activity. A great time to do this is following a diaper change or when the baby wakes up from a nap. At first, some babies may not like the tummy time position. Place yourself or a toy in front of the baby. Eventually babies will enjoy tummy time and play in this position. There are lots of ways to play with a baby during tummy time. Place yourself or a toy just out of the baby’s reach during playtime to get the baby to reach for you or the toy. Moving the toy to different locations allows the baby to develop appropriate muscles for rolling, scooting on the belly, and crawling. Lie on your back and place the baby on your chest. The baby will lift his or her head and use his or her arms to try to see your face. While being watched by an adult, have a young child play with the baby during tummy time. Young children can get down on the floor easily. They generally have energy for playing with babies, really enjoy their role as “big kid,” and are likely to have fun themselves.
- Another way to reduce the risk of SIDS is to discuss SIDS with the parents in your program.Give them SIDS materials like the Back to Sleep brochure, or the EEC SIDS handout (in their native language whenever possible). Explain the EEC regulation that requires you to place the baby on his/her back to sleep, and encourage them to place their baby on his/her back to sleep at home. Explain to parents that you must have a signed order from the baby’s doctor if you are to place the baby on his side or tummy for sleep while in your care. HANDOUT: Copy of the EEC Template Safe Sleep Certification
- As we said at the outset, all of these techniques help to reduce the risk of SIDS, but do not eliminate the risk. For that reason it is important that you have a medical emergency plan in place. Keep the plan in a visible spot such as on the wall by the baby’s crib, or at least in the room where the infants sleep. Be sure to place emergency numbers on or by each telephone in the facility or home and to have a phone that is within easy reach to use in an emergency wherever children are in care.
- If you do encounter an unresponsive infant, you should immediately: Initiate one sequence of CPR Call 911 Return to CPR Call emergency child care backup person Send/bring infant’s medical records to hospital Accompany infant to hospital, if possible Notify parents Notify supervisor if you have one or child care system Notify EEC