Infant/Toddler Safe Sleep & SIDS Risk Reduction in Child Care NEWSLETTER

On October 19, 2004, the North Carolina Healthy Start Foundation commemorated the 10th Anniversary of the North Carolina Back To Sleep (NCBTS) Campaign in partnership with Wake Med in Raleigh. Since 1994, the campaign has developed fruitful public-private partnerships across the state and has utilized a variety of media to increase the public's awareness about SIDS and risk reduction. Outreach to parents, caregivers, employers/employees such as childcare providers and directors, and health and social service professionals have been a mainstay of the campaign. The Infant/Toddler Safe Sleep and SIDS Risk Reduction (ITS-SIDS) Project is a key component of the campaign's SIDS education outreach and training. The campaign has contributed to our state's drop in SIDS deaths during the past decade. However, the number of apparently healthy infants dying suddenly and unexpectedly -about 100 each year- continues to be unacceptably high.

The N.C. Back to Sleep Campaign for SIDS Risk Reduction is committed to maximizing statewide efforts to combat SIDS and at the news conference a new initiative was announced. Through this initiative, the campaign will reach out to hospitals and assist hospital newborn nurseries in promoting infant sleep safety while in the hospital and after discharge. We hope to fortify statewide parent education about infant sleep safety and SIDS risk reduction.

Back-sleeping babies who are not experienced with sleeping on their stomachs (prone) have a 19-fold increase of SIDS if they are placed face down to sleep. Dr. Bradley T. Thach and his team of researchers at Washington University School of Medicine in St. Louis wanted to know if babies not used to sleeping on their back (unaccustomed stomach sleepers) would turn their heads so that they could breathe easier if they were placed in the unfamiliar stomach sleep-position. The results of their study are published in the December 2004 issue of Pediatrics. Studying baby's sleeping patterns, they found that babies who are not used to sleeping on their stomachs do not learn behaviors that could reduce their risk for SIDS.

The researchers studied 38 healthy infants ranging in age from 3-37 weeks whose breathing (including intake of carbon dioxide and respiration), heart rate and head movements were monitored. The Denver Development Scale was administered to assess each child's gross motor development. Two groups of babies were compared; one-half of whom usually slept on their stomachs or could roll themselves over from back to stomach and one-half of whom had never slept on their stomachs. All of the babies were placed on their stomachs to sleep and their heads were covered with soft blankets in order to study the babies' responses to elevated levels of carbon dioxide in the vicinity of their faces/heads, what the researchers called a "mildly asphyxiating micro-environment."

After about five minutes all of the babies awoke and tried to get fresh air. The experienced stomach (prone) sleepers lifted and turned their heads to either side seeking fresh air. The inexperienced stomach sleepers (those infants used to sleeping supine or on their backs) nuzzled the bedding or lifted their heads briefly and then continued sleeping facedown. This latter, inexperienced group was not able to get sufficient fresh air because their ability to escape from the asphyxiating (higher carbon dioxide) sleep environment was lower than the experienced stomach sleepers.

Paluszynska, the lead author, and colleagues suggest that babies who sleep on their stomachs learn which head movements reduce their discomfort of breathing higher amounts of carbon dioxide and that this learned response helps them avoid conditions that might result in SIDS. But, the researchers caution, this head-lifting reaction may not adequately protect against SIDS. Caregivers are advised to place babies on their back to sleep and to keep the children's heads uncovered.

Reference: Paluszynska, D.A., K. A. Harris and B.T. Thach. Influence of Sleep Position Experience on Ability of Prone-Sleeping Infants to Escape From Asphyxiating Microenvironments by Changing Head Position. Pediatrics. 2004;114.6.pp 1634-1639.

Note: In a statement released by Dr. Thach on December 6, 2004, he cautions that parents might think that if a baby can lift its head then stomach sleeping is alright… "but this is a false assurance. Parents and other caregivers should never place an infant in the prone [stomach] position until he or she shows the ability to spontaneously turn all the way over. Back-sleeping should continue to be strongly encouraged to protect against SIDS," he said.

Unaccustomed stomach sleepers

Q: Several providers have called asking for help in dealing with children who have been sleeping on their stomachs at home and are now being positioned on their backs for naps in the childcare setting. In the instances cited, the infants cry continuously and do not sleep in spite of darkened rooms, soothing music, patting, and being picked up and reassured every five minutes. These providers would gratefully welcome any suggestions that might help to calm the children used to sleeping on their stomach and enable them to adjust better to the back to sleep position.

A: Your question points to the need for consistent infant sleep safety and back sleep positioning for healthy infants beginning at birth. In the childcare setting, providers must work with parents before the baby is enrolled to promote an easier sleep time/nap time transition. When reviewing their Safe Sleep Policy with parents, providers should encourage parents to "prepare for childcare" ahead of time by adopting the same safe sleep and back to sleep standards that providers follow. Encourage parents to start an action plan for their baby's safe sleep transition with the goal of enabling the baby to sleep comfortably on his/her back by the time he starts child care. This will be less disruptive for their baby, other babies sleeping in the infant room and to the operation of the childcare facility. Everyone will rest a little easier.

I posted this fussy baby question on the Association of SIDS and Infant Mortality Programs State-To-State ListServ and received several suggestions:
1) Swaddling has been shown to promote sleep in these wakeful sleepers when they are placed on their backs. Brad Thach, MD
(Note: Swaddling is generally practiced with newborn infants and is not recommended for older babies. If swaddling is used, providers should heed the signs of overheating. Care must also be taken to ensure that the swaddle is secure to minimize unraveling and thereby lower the danger of a loose blanket covering the baby's head.)
2) If the child has a comfort item, allow him to fall asleep with it but remove it from the crib once the child falls asleep. (Note: Providers should follow their safe sleep policy regarding whether or not objects are allowed in the crib while baby sleeps.)
3) A pacifier may help calm the child. (Note: Pacifiers appear to be protective against SIDS.)
4) You asked about babies who cannot be soothed to sleep on their backs.

If someone you know has an infant who is not easily comforted or has difficulty establishing regular sleep or eating patterns, call the Fussy Baby Network at 1-888-431-BABY or 888-431-2229. The Fussy Baby Network is a program of the Erikson Institute's Graduate School in Child Development. It was launched in Chicago in March 2003 and brings together research in support of practice initiatives. The network which is geared for parents, includes a clinic, home visit program, telephone support line and parent support groups.

Contact the Fussy Baby Network by telephone or on the web at: http://www.erikson.edu/research.asp?file=rp_fussy&highlight=fussy+baby+network

Note: Readers, if you know of other safe sleep tips for fussy babies, send them to us and we'll gladly share them with others.

Twins

Q: Is there any research specifically around twin babies sleeping together in a crib regarding a greater likelihood of SIDS?

A: Although there is a greater prevalence of SIDS among twins, the primary reason for that is not because they are twins. The higher crude relative risk of SIDS in twins compared to singletons is attributable to the higher proportion of twins that are of low birthweight. John J. Park, Epidemiologist US HHS/HRSA/MCHB/ODIM 5600 Fishers LN, 18-41 Rockville, MD 20857 Reference: Platt, M.J. and Pharoah, P.O.: Arch. Dis. Child 88(1): 27-9 (2003)

A: Twins were identified in several studies to be at higher risk for SIDS than singletons,1, 2 however, not all investigators have confirmed this.3 In another recent study, the higher crude relative risk of SIDS in twins compared to singletons resulted from a higher proportion of twins having low birthweights.4 Twins of like-sex do not appear to be at a higher risk for SIDS than unlike-sex twins, suggesting that zygosity [the condition of the cell formed by a fertilized egg] is not a significant factor in SIDS.4, 5 Henry F. Krous, MD Director of Pathology, Children's Hospital-San Diego Professor of Pathology & Pediatrics, UCSD School of Medicine Director, San Diego SIDS/SUDC Research Project
References: 1. Daltveit AK, Vollset SE, Otterblad-Olausson P, Irgens LM. Infant mortality in Norway and Sweden 1975-88: a cause-specific analysis of an increasing difference. Paediatr Perinat Epidemiol. 1997;11(2):214-227. 2. Ramos V, Hernandez AF, Villanueva E. Simultaneous death of twins. An environmental hazard or SIDS? Am J Forensic Med Pathol. 1997;18(1):75-78. 3. Malloy MH, Freeman DH, Jr. Sudden infant death syndrome among twins. Arch Pediatr Adolesc Med. 1999;153(7):736-740. 4. Platt MJ, Pharoah PO. The epidemiology of sudden infant death syndrome. Arch Dis Child. 2003;88(1):27-29. 5. Peterson DR, Chinn NM, Fisher LD. The sudden infant death syndrome: repetitions in families. J Pediatr. 1980;97(2):265-267.

Q:We have a situation in child care where the pediatrician has signed a waiver to allow twins to co-sleep. I know it is safe sleep practice to have one baby per crib ... but, has there ever been any different consideration given for twins?

A: N.C. childcare regulations stipulate one child per crib unless using an evacuation crib in the event of an emergency. This is primarily a sanitation requirement and helps reduce the chances of spreading germs. The Alternative Sleep Position Waiver, Physician Recommendation should state the medical reason why exceptions to the back-to-sleep or co-sleeping requirements are being made. Other dangers with co-sleeping twins should be considered such as the potential of rebreathing expired air that has increased levels of carbon dioxide, particularly if the infants' faces are in close proximity to each other, and one child might physically obstruct the other child's airways accidentally. Chris O'Meara, ITS-SIDS (1-12-05)

A: The issue of twins sleeping in the same crib seems to be a hot question recently! It is the recommendation of our medical experts that twins not share the same sleep area for the same reason as we recommend taking pillows, blankets, toys bumpers, etc., out of the crib. The vision of a safe crib is a firm mattress, baby on back and nothing else in the crib. However, it can be beneficial to have the twins sleep next to each other in the same room but in separate cribs for the same reasons that studies show it is beneficial to room share with her baby rather than bed share. The perception of the other baby being close by may keep them from going into a deep sleep, which can reduce the risk of SIDS. Laura Reno, First Candle/SIDS Alliance (1-20-04)

Listen Up!
The North Carolina Healthy Start Foundation's Infant Mortality Awareness (IMA) Campaign will run radio and print advertisements to increase the public's awareness about SIDS and other causes of infant death in the following 13 North Carolina counties: Alamance, Caldwell, Cleveland, Columbus, Gaston, Iredell, Lenoir, Onslow, Randolph, Rutherford, Vance, Wayne, and Wilson. Expect to see and hear these messages in late March and early April.

Baby's Sleep Safety - Crib Recall
In early January 2005, the Consumer Product Safety Commission (CPSC) and Orbelle Trade Inc. issued a crib recall that warns consumers to stop using the following crib models because they do not follow crib safety standards: Daniella, Leeat, Noa, Naomi, Gabriella, Amber and Series 300 model cribs.

The Amber model crib has a gap between the side rail and crib mattress support which is an entrapment hazard. The other models do not have proper crib assembly instructions or diagrams and are missing cautionary and warning labels required by US federal law. Improper crib assembly can pose an entrapment hazard to infants.

Consumers should contact Orbelle Trade Inc at 800- 605-8018 between 9 a.m. and 4 p.m. ET Monday-Friday. The CPSC Hotline number is 800-638-2772. To view this recall online, click here: http://www.cpsc.gov/cpscpub/prerel/prhtml05/05079.html

Child Trends and the Center for Child Health Research has produced a new publication, Early Child Development in Social Context: A Chartbook (Sept. 2004). It highlights leading indicators for early childhood development including:

• socio-emotional development
• intellectual development including fine and gross motor skills
• child health
• family functioning
• parental health
• receiving health care, hearing and vision screening and immunizations
• community/neighborhood factors
• child care
• demographic factors
  

Selected findings of the individual indicators are discussed and summarized according to:

1. why they are important
2. what the data shows
3. implications for policy makers and practitioners
4. implications for parents

This publication is a concise and reader-friendly resource for anyone engaged in the field of early childhood education and care-giving including medical professionals, teachers and parents. Click here to access the publication: http://www.cmwf.org/publications/publications_show.htm?doc_id=237483

Welcome! to the 53 additional certified trainers who have joined the ITS-SIDS team. Three formerly certified ITS-SIDS trainers who are now Infant/Toddler Specialists also participated in one of the four ITS-SIDS trainings conducted in December for a total of 56 participants trained.

ITS-SIDS trainers going strong in the new year! As of December 31, 2004, a total of 25,271 childcare providers have been trained and 1,339 trainings have been scheduled or completed since the train-the-trainer sessions began in February 2003. Keep up the good work!

• Phase 1 - 10,700 childcare providers; 557 trainings scheduled or completed
• Phase 2 - 10,348 childcare providers; 534 trainings scheduled or completed
• Phase 3 - 4,223 childcare providers; 248 trainings scheduled or completed