title: Infant sleep position policies in licensed child care centers after back to sleep campaign.
abstract: BACKGROUND
  Since the Back to Sleep (BTS) campaign was initiated in 1994, the rate of prone sleeping has decreased to approximately 20%. However, child care centers may have an increased rate of prone sleeping in infants. In 1996, a study of licensed child care centers demonstrated that 43% were unaware of the association between sudden infant death syndrome (SIDS) and prone sleeping and that 49% positioned infants prone.
  
  
  OBJECTIVE
  To determine effectiveness of a mailing from the BTS campaign to licensed child care centers by assessing the following: 1) child care center awareness of the recommendations of the American Academy of Pediatrics regarding infant sleep position and 2) implementation of the recommendations of the American Academy of Pediatrics in child care center practice.
  
  
  METHODS
  A descriptive, cross-sectional survey of licensed child care centers in the metropolitan Washington, DC, region. All licensed child care centers caring for infants <6 months old in Washington, DC, and Montgomery, Prince Georges, Howard, Anne Arundel, Frederick, and Charles Counties in Maryland were recruited for the study.
  
  
  RESULTS
  Out of 236 eligible centers, 172 completed the survey. Seventy-five percent (129) of the centers were aware of recommendations regarding infant sleep position. Infants were placed prone in 27.9% of centers, although only 2.9% placed infants exclusively in the prone position. The most common reasons for avoiding prone position entirely were SIDS risk reduction and licensing regulations. Half of the centers had a written policy regarding sleep position. Twenty centers who were aware of the dangers of prone sleeping continued to placed infants prone at least some of the time, largely because of parental request. Only 56.9% of centers had heard of the BTS campaign despite the mass mailing. The mailing resulted in policy change for 14 centers.
  
  
  CONCLUSIONS
  Since 1996, the percentage of licensed child care centers in the greater Washington, DC, area that are aware of the association between SIDS and infant sleep position has increased from 57% to 75%. In addition, the rate of placing infants prone in these centers has declined from 49% in 1996 to 27.9% in this study. When child care centers are aware of the risk of prone sleeping, the most likely reason for continued prone placement is parental request. Although media and mailings have been largely effective in communicating BTS information to many child care centers, nonprone positioning is not universal among child care providers. Additional educational efforts toward child care providers and parents remain necessary.
authors.affiliation: Department of General Pediatrics and Adolescent Medicine, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org
authors.forename: R Y
authors.initials: RY
authors.lastname: Moon
authors.forename: W M
authors.initials: WM
authors.lastname: Biliter
mesh_terms: D002656:Child Day Care Centers; D003430:Cross-Sectional Studies; D004219:District of Columbia; D005069:Evaluation Studies as Topic; D006266:Health Education; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D008396:Maryland; D016684:Prone Position; D012890:Sleep