3.1.4.1: Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction

Safe sleep practices help reduce the risk of sudden unexpected infant deaths (SUIDs). Facilities should develop a written policy describing the practices to be used to promote safe sleep for infants. The policy should explain that these practices aim to reduce the risk of SUIDs, including sudden infant death syndrome (SIDS), suffocation and other deaths that may occur when an infant is in a crib or asleep. About 3,500 SUIDs occurred in the U.S. in 2014 (1). 

All staff, parents/guardians, volunteers and others approved to enter rooms where infants are cared for should receive a copy of the Safe Sleep Policy and additional educational information and training on the importance of consistent use of safe sleep policies and practices before they are allowed to care for infants (i.e., first day as an employee/volunteer/subsitute). Documentation that training has occurred and that these individuals have received and reviewed the written policy before they care for children should be kept on file. Additional educational materials can be found at https://www.nichd.nih.gov/sts/materials/Pages/default.aspx. 

All staff, parents/guardians, volunteers and others who care for infants in the child care setting should follow these required safe sleep practices as recommended by the American Academy of Pediatrics (AAP) (2):

1. Infants up to twelve months of age should be placed for sleep in a supine position (wholly on their back) for every nap or sleep time unless an infant’s primary health care provider has completed a signed waiver indicating that the child requires an alternate sleep position;
2. Infants should be placed for sleep in safe sleep environments; which include a firm crib mattress covered by a tight-fitting sheet in a safety-approved crib (the crib should meet the standards and guidelines reviewed/approved by the U.S. Consumer Product Safety Commission [CPSC] (3) and ASTM International [ASTM]). No monitors or positioning devices should be used unless required by the child’s primary health care provider, and no other items should be in a crib occupied by an infant except for a pacifier;
3. Infants should not nap or sleep in a car safety seat, bean bag chair, bouncy seat, infant seat, swing, jumping chair, play pen or play yard, highchair, chair, futon, sofa/couch, or any other type of furniture/equipment that is not a safety-approved crib (that is in compliance with the CPSC and ASTM safety standards) (3);
4. If an infant arrives at the facility asleep in a car safety seat, the parent/guardian or caregiver/teacher should immediately remove the sleeping infant from this seat and place them in the supine position in a safe sleep environment (i.e., the infant’s assigned crib);
5. If an infant falls asleep in any place that is not a safe sleep environment, staff should immediately move the infant and place them in the supine position in their crib;
6. Only one infant should be placed in each crib (stackable cribs are not recommended);
7. Soft or loose bedding should be kept away from sleeping infants and out of safe sleep environments. These include, but are not limited to: bumper pads, pillows, quilts, comforters, sleep positioning devices, sheepskins, blankets, flat sheets, cloth diapers, bibs, etc. Also, blankets/items should not be hung on the sides of cribs. Loose or ill-fitting sheets have caused infants to be strangled or suffocated (2). 
8. Swaddling infants when they are in a crib is not necessary or recommended, but rather one-piece sleepers should be used (see Standard 3.1.4.2 for more detailed information on swaddling) (2);
9. Toys, including mobiles and other types of play equipment that are designed to be attached to any part of the crib should be kept away from sleeping infants and out of safe sleep environments;
10. When caregivers/teachers place infants in their crib for sleep, they should check to ensure that the temperature in the room is comfortable for a lightly clothed adult, check the infants to ensure that they are comfortably clothed (not overheated or sweaty), and that bibs, necklaces, and garments with ties or hoods are removed. (Safe clothing sacks or other clothing designed for safe sleep can be used in lieu of blankets.);
11. Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up;
12. Bedding should be changed between children, and if mats are used, they should be cleaned between uses.

The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier (if used).

A caregiver/teacher trained in safe sleep practices and approved to care for infants should be present in each room at all times where there is an infant. This caregiver/teacher should remain alert and should actively supervise sleeping infants in an ongoing manner. Also, the caregiver/teacher should check to ensure that the infant’s head remains uncovered and re-adjust clothing as needed.

The construction and use of sleeping rooms for infants separate from the infant group room is not recommended due to the need for direct supervision. In situations where there are existing facilities with separate sleeping rooms, facilities have a plan to modify room assignments and/or practices to eliminate placing infants to sleep in separate rooms.

Facilities should follow the current recommendation of the AAP about pacifier use (2). If pacifiers are allowed, facilities should have a written policy that describes relevant procedures and guidelines. Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.
The program should encourage, provide arrangements for, and support breastfeeding. Breastfeeding or feeding an infant with their mother's expressed breast milk is also associated with a reduced risk of sleep-related infant deaths (2). 

RATIONALE

Despite the decrease in deaths attributed to sleeping practices and the decreased frequency of prone (tummy) infant sleep positioning over the past two decades, some caregivers/teachers continue to place infants to sleep in positions or environments that are not safe. Most sleep-related deaths in child care facilities occur in the first day or first week that an infant starts attending a child care program (4). Many of these deaths appear to be associated with prone positioning, especially when the infant is unaccustomed to being placed in that position (2). Training that includes observations and addresses barriers to changing caregiver/teacher practices would be most effective. Use of safe sleep policies, continued education of parents/guardians, expanded training efforts for child care professionals, statewide regulations and mandates, and increased monitoring and observation of intants while they are sleeping are critical to reduce the risk of SUIDs in child care (2). 

Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk of SUID (4,5). Recent research and demonstration projects (6,7) have revealed that:

1. Caregivers/teachers are unaware of the dangers or risks associated with prone or side infant sleep positioning, and many believe that they are using the safest practices possible, even when they are not;
2. Although training programs are effective in improving the knowledge of caregivers/teachers, these programs alone do not always lead to changes in caregiver/teacher practices, beliefs, or attitudes; and 
3. Caregivers/teachers report the following major barriers to implementing safe sleep practices:They have been misinformed about methods shown to reduce the risk of SUID;

COMMENTS

Background: Deaths of infants who are asleep in child care may be under-reported because of the lack of consistency in training and regulating death scene investigations and determining and reporting cause of death. Not all states require documentation that clarifies that an infant died while being cared for by someone other than their parents/guardians.

Although the cause of many sudden infant deaths may not be known, researchers believe that some infants develop in a manner that makes it challenging for them to be aroused or to breathe when they experience a life-threatening challenge during sleep. Although some state regulations require that caregivers/teachers “check on” sleeping infants every ten, fifteen, or thirty minutes, an infant can suffocate or die in only a few minutes. It is for this reason that the standards above discourage toys or mobiles in cribs and recommend direct, active, and ongoing supervision when infants are falling to sleep, are sleeping, or are becoming awake. This is also why Caring for Our Children describes a safe sleep environment as one that includes a safety-approved crib, firm mattress, firmly fitted sheet, and the infant placed on their back at all times, in comfortable, safe garments, but nothing else – not even a blanket.

When infants are being dropped off, staff may be busy. Requiring parents/guardians to remove the infant from the car seat and re-position them in the supine position in their crib (if they are sleeping), will reinforce safe sleep practices and reassure parents/guardians that their child is in a safe position before they leave the facility.

Challenges: National recommendations for reducing the risk of SUIDs are provided for use in the general population. Most research reviewed to guide the development of these recommendations was not conducted in child care settings. Because infants are at increased risk for dying from sleep-related causes in child care (4,5), caregivers/teachers must provide the safest sleep environment for the infants in their care.

When hospital staff or parents/guardians of infants who may attend child care place the infant in a position other than supine for sleep, the infant becomes accustomed to this and can have a more difficult time adjusting to child care, especially when they are placed for sleep in a new unfamiliar position.

Parents/guardians and caregivers/teachers want infants to transition to child care facilities in a comfortable and easy manner. It can be challenging for infants to fall asleep in a new environment because there are different people, equipment, lighting, noises, etc. When infants sleep well in child care, adults feel better. Placing personal items in cribs with infants and covering or wrapping infants with blankets may help the adults to believe that the child is more comfortable or feels comforted. However, this may or may not be true. These practices are not the safest practices for infants in child care, and they should not be allowed. Efforts to educate the public about the risk of sleep-related deaths promoting the use of consistent safe sleep practices need to continue.

Special Care Plans: Some facilities require staff to place infants in a supine position for sleep unless there is documentation in a child’s special care plan indicating a medical need for a different position. This can provide the caregiver/teacher with more confidence in implementing the safe sleep policy and refusing parental demands that are not consistent with safe sleep practices. It is likely that an infant will be unaccustomed to sleeping supine if his or her parents/guardians object to the supine position (and are therefore placing the infant prone to sleep at home). By providing educational information on the importance of consistent use of safe sleep policies and practices to expectant parents, facilities will help raise awareness of these issues, promote infant safety, and increase support for proper implementation of safe sleep policies and practices in the future.

Use of Pacifiers: Caregivers/teachers should be aware of the current recommendation of the AAP about pacifier use to reduce the risk of SUIDs (2). While using pacifiers to reduce the risk of SIDS seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has also been shown to be associated with an increased risk of ear infections. Keeping pacifiers clean and limiting their use to sleep time is best. Using pacifiers in a sanitary and safe fashion in group care settings requires special diligence.

Pacifiers should be inspected for tears before use. Pacifiers should not be clipped to an infant’s clothing or tied around an infant’s neck.

For children in the general population, the AAP recommends the following:

1. Child care faciltites require written permission from the child’s parent/guardian for pacifier use;
2. Consider offering a pacifier when placing the infant down for nap and sleep time;
3. If the infant refuses the pacifier, s/he should not be forced to take it;
4. If the infant falls asleep and the pacifier falls out of the infant’s mouth, it should be removed from the crib and does not need to be reinserted. A pacifier has been shown to reduce the risk of SIDS, even if the pacifier falls out during sleep (2);
5. Pacifiers should not be coated in any sweet solution, and they should be cleaned and replaced regularly; and
6. For breastfed infants, delay pacifier introduction until fifteen days of age to ensure that breastfeeding is well-established (2).

Swaddling: Hospital personnel or physicians, particularly those who work in neonatal intensive care units or infant nurseries in hospitals may recommend that newborns be swaddled in the hospital setting. Although parents/guardians may choose to continue this practice at home, swaddling infants when they are being placed to sleep or are sleeping in a child care facility is not necessary or recommended. See Standard 3.1.4.2 for more detailed information.

Concern about Plagiocephaly: If parents/guardians or caregivers/teachers are concerned about positional plagiocephaly (flat head or flat spot on head), they can continue to use safe sleep practices but also do the following:

1. Offer infants opportunities to be held upright and participate in supervised “tummy time” when they are awake;
2. Alter the position of the infant, and thereby alter the supine position of the infant’s head and face. This can easily be accomplished by alternating the placement of the infant in the crib – place the infant to sleep with their head facing to one side for a week and then turning the infant so that their head and face are placed the other way. Infants typically turn their head to one side toward the room or door, so if they are placed with their head toward one side of the bed for one sleep time and then placed with their head toward the other side of the bed the next time, this changes the area of the head that is in contact with the mattress.

A common question among caregivers/teachers and parents/guardians is whether they should return the infant to the supine position if they roll onto their side or their tummies. Infants up to twelve months of age should be placed wholly supine for sleep every time. In fact, all children should be placed (or encouraged to lie down) on their backs to sleep. When infants are developmentally capable of rolling comfortably from their backs to their fronts and back again, there is no evidence to suggest that they should be re-positioned into the supine position.

The California Childcare Health Program has available a Safe Sleep Policy for Infants in Child Care Programs. AAP provides a free online course on safe sleep practices.

 

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.6.1 Strangulation Hazards
3.6.4.5 Death
4.3.1.1 General Plan for Feeding Infants
4.5.0.3 Activities that Are Incompatible with Eating
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
6.4.1.3 Crib Toys
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances

REFERENCES

1. U.S. Centers for Disease Control and Prevention. 2016. About SUID and SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm. 
   
2. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
   https://pediatrics.aappublications.org/content/138/5/e20162938.
   
3. U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs.
   
4. First Candle. 2016. SIDS and daycare: A fatal combination. http://www.firstcandle.org/sids-and-daycare-a-fatal-combination/. 
   
5. Healthy Child Care America. 2012. A child care provider’s guide to safe sleep. Helping you to reduce the risk of SIDS. http://www.healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf. 
   
6. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
   
7. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79.
   
8. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? Pediatrics 155:350-54.
   
9. UCSF California Childcare Health Program (CCHP). 2016. Safe sleep policy for infants in child care programs. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-Policy.
   
10. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note. 
    
11. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM. 
    
12. Centers for Disease Control and Prevention. 2013. Sudden infant death syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/.
    
13. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe sleep ® campaign materials. 2014. https://www.nichd.nih.gov/sts/materials/Pages/default.aspx.
    

NOTES

Content in the STANDARD was modified on 12/05/2011 and on 12/1/2016.

3.1.4.2: Swaddling

In child care settings, swaddling is not necessary or recommended.

RATIONALE

There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6).

COMMENTS

Most infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction

REFERENCES

1. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
   
2. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants. J Pediatrics 157:85-91.
   
3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.
   
4. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Pediatrics 120:e1097-e1106.
   
5. Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental dysplasia of the Hip? Pediatrics 121:177-78.
   
6. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 115:1307-11.
   

3.1.4.3: Pacifier Use

Facilities should be informed and follow current recommendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3).

If pacifiers are allowed, facilities should have a written policy that indicates:

1. Rationale and protocols for use of pacifiers;
2. Written permission and any instructions or preferences from the child’s parent/guardian;
3. If desired, parent/guardian should provide at least two new pacifiers (labeled with their child’s name using a waterproof label or non-toxic permanent marker) on a regular basis for their child to use. The extra pacifier should be available in case a replacement is needed;
4. Staff should inspect each pacifier for tears or cracks (and to see if there is unknown fluid in the nipple) before each use;
5. Staff should clean each pacifier with soap and water before each use;
6. Pacifiers with attachments should not be allowed; pacifiers should not be clipped, pinned, or tied to an infant’s clothing, and they should not be tied around an infant’s neck, wrist, or other body part;
7. If an infant refuses the pacifier, s/he should not be forced to take it;
8. If the pacifier falls out of the infant’s mouth, it does not need to be reinserted;
9. Pacifiers should not be coated in any sweet solution;
10. Pacifiers should be cleaned and stored open to air; separate from the diapering area, diapering items, or other children’s personal items.

Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up. The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier.

Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.

Caregivers/teachers should work with parents/guardians to wean infants from pacifiers as the suck reflex diminishes between three and twelve months of age. Objects which provide comfort should be substituted for pacifiers (6).

RATIONALE

Mobile infants or toddlers may try to remove a pacifier from an infant’s mouth, put it in their own mouth, or try to reinsert it in another child’s mouth. These behaviors can increase risks for choking and/or transmission of infectious diseases.

Cleaning pacifiers before and after each use is recommended to ensure that each pacifier is clean before it is inserted into an infant’s mouth (5). This protects against unknown contamination or sharing. Cleaning a pacifier before each use allows the caregiver/teacher to worry less about whether the pacifier was cleaned by another adult who may have cared for the infant before they did. This may be of concern when there are staffing changes or when parents/guardians take the pacifiers home with them and bring them back to the facility.

If a caregiver/teacher observes or suspects that a pacifier has been shared, the pacifier should be cleaned and sanitized. Caregivers/teachers should make sure the nipple is free of fluid after cleaning to ensure the infant does not ingest it. For this reason, submerging a pacifier is not recommended. If the pacifier nipple contains any unknown fluid, or if a caregiver/teacher questions the safety or ownership, the pacifier should be discarded (4).

While using pacifiers to reduce the risk of sudden infant death syndrome (SIDS) seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has been associated with an increased risk of ear infections and oral health issues (7).

COMMENTS

To keep current with the AAP’s recommendations on the use of pacifiers, go to http://www.aap.org.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.3 Oral Health Education
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.4.6.1 Strangulation Hazards

REFERENCES

1. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
   https://pediatrics.aappublications.org/content/138/5/e20162938.
   
2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend? Pediatrics117:1811-12.
   
3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 117:1755-58.
   
4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care 9:12-13.
   
5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65.
   
6. American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008. Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.
   
7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/pacifiers/art-20048140.
   

NOTES

Content in the STANDARD was modified on 12/5/2011. 

3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for all children and age appropriate sleep/nap environment (See Standard 5.4.5.1). For children who are unable to sleep, the facility should provide time and space for quiet play. A facility that includes preschool-aged and school-aged children should make books, board games, and other forms of quiet play available.

Facilities that offer infant care should provide a safe sleep environment and use a written safe sleep policy that describes the practices they follow to reduce the risk of sudden infant death syndrome and other infant deaths. For example, when infants fall asleep, they must be put down to sleep on their back in a crib with a firm mattress and no blankets or soft objects.

RATIONALE

Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times and duration of naps will affect behavior at home (1).

Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered breathing all peak during the preschool years. In 2016, the National Sleep Foundation issued recommended sleep durations for newborns (14–17 hours), infants (12–15 hours), toddlers (11–14 hours), and preschoolers (10–13 hours), which include both daytime and nighttime sleep (2,3).Getting sufficient sleep helps prevent pediatric obesity. In meta-analyses, short sleep duration before 5 years of age is associated with 30% to 90% increased odds of overweight/obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to counsel parents about recommended sleep durations (6). Behavioral sleep problems (i.e., difficulty getting to/falling asleep) at 18 months of age are associated with a 60% to 80% increased risk of emotional and behavioral problems at 5 years of age (7). Irregular bedtimes throughout early childhood are associated with reduced reading, math, and spatial ability scores (8). Sleep-disordered breathing (e.g., snoring, apnea) in early childhood is associated with a 60% to 80% increase in social and emotional difficulties at 7 years of age (9).

COMMENTS

In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may need 1 or 2 (or sometimes more) naps during the time they are in child care. As infants age, they typically transition to 1 nap per day, and having 1 nap per day is consistent with the schedule that most facilities follow. Different practices, such as rocking, holding a child while swaying, singing, reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during nap time.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.2.2.1 Levels of Illumination
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs

REFERENCES

1. National Sleep Foundation. How much sleep do we really need? https://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need. Accessed November 14, 2017

2. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561

3. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149

4. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385

5. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

6. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582

7. Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based study. Journal of Epidemiology and Community Health , 67 (11) pp. 926-931.

8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857–e865

NOTES

Content in the STANDARD was modified on 05/30/2018.

3.1.4.5: Unscheduled Access to Rest Areas

All children should have access to rest or nap areas whenever the child desires to rest. These rest or nap areas should be set up to reduce distraction or disturbance from other activities. All facilities should provide rest areas for children, including children who become ill (1,2), at least until the child leaves the facility for care elsewhere. Children need to be within sight and hearing of caregivers/teachers when resting.

RATIONALE

Any child, especially children who are ill (1,2), may need more opportunity for rest or quiet activities.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
5.4.5.1 Sleeping Equipment and Supplies
5.4.6.1 Space for Children Who Are Ill
Appendix A: Signs and Symptoms Chart

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020:45-50.
2. American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 125-136, 122-125, 124t