title: Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies.
abstract: BACKGROUND
  Millions of children in the US have parents who work alternative shifts. As a result, extended-hour and nighttime child care centers have increased in number to meet the needs of parents working nonstandard hours. Recognizing that 20% of sudden infant death syndrome (SIDS) occurs in child care settings and that child care providers may place infants prone, it is important to determine sleep position practices in nighttime child care centers.
  
  
  OBJECTIVE
  To determine if nighttime child care centers 1) follow Back to Sleep recommendations; 2) are aware of the need for a safe sleep environment; and 3) have written policies directing proper SIDS risk reduction practices.
  
  
  METHODS
  A descriptive, cross-sectional survey of licensed child care centers in the US offering evening and nighttime care. All nighttime centers caring for infants <6 months old were recruited for the study.
  
  
  RESULTS
  Out of 153 eligible centers, 110 centers in 27 states completed the survey. Infants were placed prone in 20% of centers, although only 1 center placed infants exclusively prone. Infants slept in cribs in 53.6% of centers, but slept in uncluttered sleep environments in only 18.2% of centers. Smoking was prohibited in 86.4% of centers. The most commonly cited reason for avoiding prone altogether was SIDS risk reduction; however, 10 centers that cited SIDS risk reduction continued to place infants prone at least some of the time, because of parental request or concerns about infant comfort. Over half (59%) of the centers had written policies; however, presence of written policy was not associated with avoidance of prone position. In over one third of centers with written policies, providers were unaware of the content of the policy.
  
  
  CONCLUSIONS
  Twenty percent of nighttime child care centers place infants prone at least some of the time. Most providers who place infants prone do so because of lack of awareness or misinformation about safe sleep environment. Although the Back to Sleep campaign has been effective in communicating the risks of sleeping prone, nonprone positioning is not universal among nighttime child care providers. Additional educational efforts toward child care providers remain necessary. In addition, parents as advocates for their own infants need to be proactive in assuring that safe sleep practices are implemented in child care settings.
authors.affiliation: Division of General and Community Pediatrics, Children's National Medical Center, Washington, DC 20010, USA. rmoon@cnmc.org
authors.forename: Rachel Y
authors.initials: RY
authors.lastname: Moon
authors.forename: Debra E
authors.initials: DE
authors.lastname: Weese-Mayer
authors.forename: Jean M
authors.initials: JM
authors.lastname: Silvestri
mesh_terms: D003430:Cross-Sectional Studies; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000331:legislation & jurisprudence* / Q000592:standards*; D007231:Infant, Newborn; D008004:Licensure / Q000592:standards*; D009551:Night Care / Q000331:legislation & jurisprudence* / Q000592:standards*; D016134:Organizational Policy; D011187:Posture / Q000502:physiology; D017410:Practice Guidelines as Topic / Q000592:standards*; D016684:Prone Position / Q000502:physiology; D012307:Risk Factors; D012308:Risk Management / Q000331:legislation & jurisprudence / Q000592:standards; D012890:Sleep / Q000502:physiology; D012907:Smoking / Q000009:adverse effects; D013398:Sudden Infant Death / Q000517:prevention & control*; D013577:Syndrome; D014481:United States