When a seemingly healthy infant dies suddenly and unexpectedly in a child care program, it can be devastating; not only for the family of the child, but also for the child care provider and other families in the program. Safe infant sleep practices and environments reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.

SIDS is the death of an infant younger than 1 year of age that can’t be explained after a thorough scene investigation, autopsy, and review of the clinical history. Ninety percent of SIDS deaths occur before an infant reaches 6 months of age. SIDS deaths peak between 1 and 4 months of age. Risk factors for SIDS include: unsafe sleep practices and environments; a critical period of development; and the individual vulnerability of an infant. Other sleep-related infant deaths (such as suffocation, asphyxia, entrapment, and strangulation) have similar risk factors.

Studies show that deaths from SIDS in child care programs were more likely to occur during the first week. SIDS deaths were more likely to occur when infants were:

• used to sleeping on their backs at home and were placed on their stomachs for sleep in child care,
• allowed to sleep in an unsafe sleep environment in child care (for example: a car seat, stroller, futon, pillow, or bean bag) (Kassa, Moon, Colvin, 2016).

The American Academy of Pediatrics (AAP) recom- mends a safe infant sleep environment and safe infant sleep practices to reduce the risk for SIDS and other sleep-related infant deaths. (AAP, 2016)

Infant Sleep in Licensed Child Care Programs in California

To reduce the risk of SIDS and other sleep-related infant deaths, licensed child care providers in California are required to:

• Place infants up to 12 months old on their backs for sleeping.
• Use a crib or portable crib (play yard) that meets the United States Consumer Product Safety Commission (CPSC) safety standards with a firm mattress made for that size crib. Cover it with a tightly-fitted sheet that is the correct size for the mattress.
• Assign a crib or play yard to each infant, and place only one infant in a crib.
• Remove any loose articles or objects, including blankets, pillows, toys and stuffed animals in, attached to, or draped over the side of the crib. Do not use bumper pads. Remove bibs, clothing with ties or hoods, and jewelry. Do not cover an infant’s head while sleeping.
• If an infant falls asleep before being placed in a crib, move the infant to a crib as soon as possible. Do not allow infants to sleep on a couch, sofa, armchair, cushion, futon, bed, or pillow; or in a car seat, stroller, swing or bouncy chair.
• Observe sleeping infants by sight and sound at all times.
• Physically check sleeping infants every 15 minutes for signs of distress or overheating. Keep a log of the time, date, and infant’s name for each 15-minute check.
• Offer a pacifier, if provided by the infant’s family. Do not attach a pacifier to a string or ribbon to be worn around an infant’s neck or fastened to an infant’s clothing. Infants may not share pacifiers.
• Do not swaddle infants for sleep. Do not dress infants in clothing that is meant to swaddle them, for example clothing that uses weights or Velcro to restrict their movement.
• Sleep sacks can not be used in Family Child Care Homes and require a waiver in Child Care Centers. Use a footed sleeper instead.
• Complete an Individual Infant Sleeping Plan (LIC 9227) for all infants up to 12 months old.  This plan must be signed and dated by the infant’s parent or guardian.
• Once an infant can roll from their back to their stomach and stomach to their back, fill out Section D of the Individual Infant Sleeping Plan (LIC 9227), and notify the parent or guardian to sign and date the form. Continue to place the infant on their back for sleep. If the infant changes position, the infant may remain in the position.

What Else Can Child Care Providers Do?

Enforce no-smoking laws and regulations
Infants who are exposed to smoke have a higher risk of dying from SIDS. California Child Care Licensing Regulations prohibit smoking in licensed child care centers and in family child care homes. California law prohibits smoking in a car when children are present.

Provide healthy air
Provide a sleeping area that is well ventilated (the air should not be stuffy and stale) and at a temperature that is comfortable for a lightly clothed adult.

Be breastfeeding friendly
Breastfeeding is associated with a lower risk of SIDS. In many cases, returning to work is a barrier to breastfeeding. Support mothers to continue breastfeeding after their maternity leave is over and they return to their work or school schedules. For detailed information on how to support breastfeeding families (including a sample policy; an infant feeding plan template; and information on safely handling, storing, and feeding breastmilk), see Supporting Breastfeeding Families, a Toolkit for Child Care Providers.

Educate families and provide professional development for staff

• Discuss safe infant sleep practices with families. Include information about: room-sharing without bed-sharing, breastfeeding, not allowing infants to routinely sleep in car seats, not smoking around infants, and keeping up with scheduled immunizations.
• Distribute written handouts, and put up posters on your walls or bulletin boards. Provide information about safe sleep upon enrolling new families.
• Provide staff development on the principles of safe infant sleep. Closely monitor staff compliance with your safe sleep policy. Review your emergency response system with all staff members on a regular basis.
• Reach out to the SIDS Coordinator at your local health department for support with family education and staff development.

Provide supervised “Tummy Time” when infants are awake
Tummy time is important for infant growth and development. It builds muscle strength and coordination in the head, neck, shoulders, abdomen, and back that are needed to reach important developmental milestones (such as how to push up, roll over, sit up, crawl, and pull to a stand). Infants must be awake and supervised for Tummy Time. See the CCHP Health & Safety Note, Tummy Time for Infants.
 

Ensure crib safety
Do not resell, donate or give away a crib that does not meet the current crib standards. CPSC recommends disassembling an old crib before discarding it. Local public health departments and advocacy groups can help provide low-cost or free cribs or play yards for families and child care providers with financial need.

If a baby is found unresponsive with no breathing or pulse, begin CPR and call 9-1-1.

References & Resources

• Moon, R., Carlin, R., Hand, I. and The Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. (2022). Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics, 150(1): e2022057990. Accessed at https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022
• Caring for Our Children National Health and Safety Performance Standards at http://nrckids.org/CFOC/Database/3.1.4.1
• California Department of Public Health Sudden Infant Death Program, SIDS Coordinators. https://www.cdph.ca.gov/Programs/CFH/DMCAH/SIDS/Pages/Sites.aspx
• Kassa, H., Moon, R., Colvin, J., Risk Factors for Sleep-Related Infant Deaths in In-Home and Out-of-Home Settings, Pediatrics, November 2016
• United States Consumer Product Safety Center (CPSC) Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs
• California Department of Social Services (CDSS), Child Care Licensing, Safe Sleep in Child Care. https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
• Los Angeles Department of Public Health, Supporting Breastfeeding Families, a Toolkit for Child Care Providers. http://www.publichealth.lacounty.gov/mch/CAH/Breastfeeding_toolkit_May2016_C.PDF