1. Infant Safe Sleep in Child Care Settings Ann Halbower Professor of Pediatrics, Pulmonary Section Children's Hospital Colorado The University of Colorado School of Medicine Colleen Kapsimalis Colorado Child Fatality Prevention System Colorado Department of Public Health and Environment

2. Financial Disclosures Funding: NIH, and Department of Pediatrics, UCD Medical advisor: AVISA device company, unrelated Ann C Halbower

3. 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

4. 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

5. Sleep-Related Infant Deaths Sudden and unexpected infant death (SUID) Most occur during sleep ◦Suffocation, strangulation, entrapment ◦Undetermined ◦SIDS

6. SUID AGE Immature Nervous System Sleep Cardio- Respiratory Control Environment Genetics

7. 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 mother African/Native American Recent infection in baby Unemployment

8. Identifying Modifiable Risk Factors New 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)

9. Some Risk Factors for Infant Death can be controlled

10. 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))

11. Position of Sleep Can be Changed Prone Positioning: Face Down on the Stomach

12. 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)

13. 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+

14. Healthy Mothers, Healthy Infants Coalition of North Florida

15. Paluszynska, Pediatrics 2004; 114:6

16. SIDS and the Prone Position Pharyngeal collapsibility is increased in the prone infant, (worsened by head turned to side) (Ishikawa, AJRCCM 2002)

17. SIDS and the Prone Position: Cons Significant 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 )

18. 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

19. Hyperthermia and SIDS High Body Temperature Decrease sensitivity to CO2 and low oxygen Decrease protective cough reflexes Increase periodic breathing Increase deep sleep without arousal Association of hyperthermia to prone position

20. 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

21. 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

22. Face Covering and SIDS Covering 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)

23. Modifiable Risk Factors for unexpected death in infants Sleep on soft bedding/mattress Bed sharing with one or more people Risk of death increased if infant slept alone in adult bed Risk of SIDS increased if infant slept in a separate room (10.49) Risk sleeping on a sofa (50)

24. 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

25. Baby Propping Propping babies for reflux: No evidence that it improves reflux Car seats increase reflux Airway instability when head falls to side Children roll to bottom  Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years : 2005. Cochrane Collaboration

26. Child Care and SUID Between 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.

27. 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

28. 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

29. Findings from National Study of Child Care Providers Training child care providers improves knowledge and practices  Sleep position  Lessens use of loose and soft bedding No change in provider attitudes about whether sleep position makes a difference  Policies and regulations are critical! Barriers: perceived parental objections, provider skepticism, lack of policies and training opportunities (Moon, 2008)

30. 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

31. AAP Recommendations: Pertinent to Child Care Sleep position Plagiocephaly Pacifiers Soft bedding Overheating

32. 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

33. 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

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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Do not use pacifier attachments

41. 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

42. Sleep Clothing Alternative to blankets Cotton or fleece

43. 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

44. 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

45. 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

46. 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

47. www.healthychildcare.org/doc/SIDSSamplePolicy.doc

48. 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

50. Partners and Resources

51. Healthy Child Care America Safe Sleep Resources American Academy of Pediatrics 141 Northwest Point Blvd Elk 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

53. 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

54. Online Child Care Provider Training Curriculum Revised in 2011 Supporting documents http://www.healthychil dcare.org/sids.html http://www.healthychil dcare.org/sids.html

55. Safe to Sleep campaign 1-800-505- CRIB http://www.nich d.nih.gov/SIDS/

56. 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

57. 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

58. CJ Foundation for SIDS 888/8CJ-SIDS (825-7437) www.cjsids.com

59. 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.cochildfa talityprevention.com/ p/safe-sleep.html http://www.cochildfa talityprevention.com/ p/safe-sleep.html

60. Questions/Discussion