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Health Consultants For Child Care

Enhancing Health, Safety & Learning for Minnesota Child Care Providers since 1993

All of these concerns discussed are important in the child care setting.  However, there are a few other factors that need to be taken into consideration when providing safe sleep in the child care setting.  Twenty percent (20%) of SIDS deaths occur while an infant is in the care of a non-parental caregiver.  Fourteen percent (14%) of these cases occur in a child care center or family child care home.  Most of these infants die because they are placed prone.

Studies suggest that the phenomenon of “unaccustomed prone sleeping” may be partly responsible for these SIDS deaths.  Unaccustomed prone sleeping is a term used to define the practice of placing an infant to sleep on their tummy when they are used to sleeping on their back.  These infants are at extremely high risk of SIDS – as much as 18 times the risk compared with non-prone (back) sleepers.

What if I have a parent that insists that his/her infant not sleep on his/her back or want to use a “wedge” or other commercial device marketed to reduce the risk of SIDS?

For some babies a medical condition or disorder may require an infant to be placed in positions other than their back when sleeping. There are guidelines for health care providers to follow to determine if the risk of death from medical complications outweighs the risk of SIDS.   This recommendation must be indicated in writing on a “Physician Directive for Alternate Sleep Position” form for a provider to place an infant to sleep in any other sleep position (not location) besides the back.  Parental authorization is also required for a medical waiver. (See page 11, Let’s Talk About Minnesota) Written safe sleep program policies must indicate “Back-To-Sleep” as a program mandatory safe sleep requirement.

“Wedge” and other commercial devices that are used to maintain a sleep position or reduce the risk of re-breathing are not recommended by the AAP, nor have they been tested for safety or effectiveness. Parental request for use of such devices should be addressed regarding these issues.  For a medical condition, a signed waiver by a parent & the health care provider must be obtained for their use in a child care setting.

What about swaddling?

Some cultures still practice swaddling.  Swaddling is when an infant (up to 3-4 months of age) is wrapped up tightly in a blanket, much like a papoose.  Hospital personnel or physicians who work in newborn nurseries or with premature babies may recommend that newborns be swaddled in a hospital setting.  Although parents/guardians may choose to continue this practice at home, the updated AAP guidelines clearly state, “No swaddling in child care facilities.  Swaddling may increase the risk of SIDS, reduce lung capacity and interfere with proper growth of the hip socket.” 

                   IMPORTANT LEGISLATIVE UPDATE 2013 See page 11, Let’s talk about Minnesota.

Do we have to remove all blankets from cribs?

 In 1999, the Consumer Product Safety Commission (CPSC), the AAP and the National Institute of Child Health and Human Development (NICHD) revised their recommendations for putting infants down to sleep. These experts recommended that, “infants under 12 months to be put to sleep in a crib with no soft bedding of any kind under or on top of the baby.  The AAP 2005 (reaffirmed in 09, 16) continued to warn against the hazards of loose bedding including blankets.  Guidelines suggested using a sleeper or other sleep clothing as an alternative to blankets with no other covering.  There are no blankets for the infant to kick and move towards its face.  The current AAP 2011 guidelines clearly outline removing “ALL” loose bedding including blankets and sheets.

MN 2013 DHS regulations allow pacifiers as the only item in a crib; one-piece blanket sleepers are allowed

 Child care providers who do not follow current recommendations for infant sleep position and bedding may be at risk for legal action if an infant dies of SUID while in their care.12 Programs are to develop and enforce written policies regarding safe sleep practices including a blanket free environment. According to MN safe sleep guidelines, infants over one year of age may have a blanket.  However, it may be easier to monitor a blanket free infant room rather than police who is over one year and may have a blanket.  Always make sure a baby’s head stays uncovered while sleeping. 

Does a baby have to sleep in its crib?

Under the division of licensing, all programs must have an approved crib for an infant it serves.  A crib provides a sleep environment, not a play environment.  It is your responsibility to provide a safe sleep/crib environment and to eliminate modifiable risk factors.  Crib sleeping also develops good life-long sleep habits. Crib inspections must be performed monthly and documented on the appropriate crib inspection form.

The AAP guidelines state, “No sleeping in sitting devices, (swings, car seats, infant seats, etc.) except when the infant sleeps while traveling in a vehicle”.  Travel time should be brief.  Sitting in seats may lower blood oxygen levels of infants. 

Program policies should address the practice of handling an infant that arrives to a program that is asleep in a car safety seat.  The infant should be immediately removed from the seat, aroused, and placed on its back in its own crib.

When is a good time to inform a parent of our program’s safe sleep policies?

When new parents or guardians come to visit your program take the time to discuss your program’s policies and licensing mandates regarding safe sleep environments.  This is the time to discuss subjects like swaddling, crib sleeping and blanket free environments.  You can even give them a copy of your written policies or parent handbook.  There are many things that parents need to consider when choosing someone to provide care for their children.  You can communicate and role model safe sleep practices as they tour your program.

If I follow these recommendations, can I be sure that a baby won’t die of SIDS while in my care?

While we are hopeful that following these recommendations will save lives, we know that following them faithfully will not prevent all SIDS deaths.2 Sleep supervision requirements such as sight, hearing and in-person checks are additional measures to ensure safe sleep but, things can still go wrong.  Neither parents nor doctors can tell which babies will die of SIDS.  It is important to note that if a baby in your care is found not breathing, the CAB’s of resuscitation should be assessed and an attempt to resuscitate, with an appropriate size CPR barrier, should always be performed.  Although SIDS is irreversible, another SUID condition may be affecting the baby for which CPR may be life saving.

References: First Candle/SIDS Alliance, Caring for Our Children, NHSPSG, Child Health Alert, NSIDPSC, American Academy of Pediatrics, Minnesota SIDS Center