CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

OVERVIEW: Sudden Infant Death Syndrome (SIDS) is the sudden and unexpected death of a seemingly healthy infant aged 12 months or younger. SIDS cannot be predicted or prevented, but the chances of a SIDS occurrence can be significantly reduced with implementation of safe sleep practices. “Caring for our Children: National Health and Safety Performance Standards Guidelines for Early Care and Education Programs” recommends the use of safe sleep environments, including the use of firm sleep surfaces, placing infants to sleep on their backs, and limiting loose bedding and soft items placed in the crib with infants. This enclosure provides additional requirements not included in the 2013 Safe Sleep Policy Letter. Child and Youth Programs (CYP) shall ensure the revised guidance is implemented to ensure safe sleep environments are promoted. SLEEP SURFACES REQUIREMENTS: Full Size Cribs 1. CYP shall follow the recommendations of CPSC based on the standards developed by the American Society for Testing and Materials (ASTM) for safety-approved cribs. The current mandatory crib standards impose significant requirements on full-size cribs. The CPSC safety regulation provided two compliance dates: a. Effective 28 June 2011, cribs offered for sale, contracted to sell or resell, manufactured, offered, provided for use, or otherwise placed in the stream of U.S. commerce must comply with the new federal crib standards; and b. Effective 28 December 2012, cribs that child care facilities, family child care homes, and places of public accommodation affecting commerce provided for use must comply with current CPSC crib standards. 2. Policy letter dated 5 June 2012 “Navy Child and Youth Programs (CYP) Supplemental Funding for Replacement of Baby Cribs” provided funding to regions for crib replacement to meet the above guidelines. If programs have cribs that were manufactured prior to 28 June 2011, they are required to discontinue use immediately and replace all non- compliant cribs. 3. Programs can determine compliance through the registration form or tracking label that is supplied from the crib manufacturer. a. Programs should keep registration information on file as documentation of compliance; and b. If the tracking label on the crib indicates that the crib was manufactured after 28 June 2011, no additional documentation is necessary to determine compliance; or

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

c. If the registration form or the tracking label is not available for any crib, said crib shall be immediately replaced to ensure compliance. 4. Only firm mattresses and fitted sheets shall be used in cribs. 5. More information on required safety standards for full size cribs can be found at the following website: http://www.cpsc.gov/onsafety/2012/12/dec-28-crib-standard-deadline-fastapproaching/. Pack-n-Plays (aka - non-full sized cribs or portacribs) 1. In addition to compliant cribs, the Child Development Homes (CDH) Program is authorized to use CPSC-approved pack-n-plays for sleeping infants. If cribs are used, they must meet CPSC standards as described above. CPSC classifies pack-n-plays as a type of “play yard” and beginning 27 February 2013, manufacturers and importers of infant and toddler play yards were required to test their play yards to ensure that they meet new federal safety standards. 2. Pack-n-plays that meet the current safety standard must have: a. Side rails that do not form a sharp V when the product is folded. This prevents a child from strangling in the side rail; b. Stronger corner brackets to prevent sharp-edged cracks and to prevent a side-rail collapse; and c. Sturdier mattress attachments to the play yard floor to prevent children from getting trapped or hurt. 3. In order to ensure that the pack-n-plays used by CDH providers and those maintained in the CDH Lending Library meet the current CPSC safety standards, CDH Programs will complete the following: a. Conduct a visual inspection of all pack-n-plays in the Lending Library and CDH homes to ensure they meet the above guidelines; b. If a determination is made that current pack-n-plays do not meet new safety standards, discontinue use immediately and replace pack-n-plays in the Lending Library; and c. Provide written guidance to current and new providers about the requirement to use only CPSC-compliant cribs and pack-n-plays.

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

4. Original mattresses, replacement mattress that meet above requirements, and fitted sheets shall be used in pack-n-plays. 5. More information on new safety standards for non-full size cribs can be found at: http://www.cpsc.gov/onsafety/2013/02/play-yards-new-safety-rule-to-take-effect/. SAFE SLEEP PRACTICES 1. All infants 12 months and younger must be placed on their backs to sleep, regardless of whether or not they are developmentally capable of rolling over. The only exception would be a medically documented alternate sleep position, which much be indicated on a Back to Sleep Placard. 2. A Back to Sleep Placard shall only be placed on the cribs or pack-n-plays of infants that are developmentally capable of rolling over from front to back and back to front (this developmental skill shall be observed in the program before displaying the placard) or have a diagnosed medical condition that warrants an alternate sleep position. a. If an infant does not meet either of the requirements (rolling over or medical condition) described above, then a Back to Sleep Placard should not be placed on the crib or pack-n-play; b. The Back to Sleep Placard shall be prominently displayed in a clear sheet protector attached to or immediately above the infant’s assigned crib or pack-n-play. The placard should not be placed in a location accessible to the infant; c. There are two distinct placards for use, both of which can be downloaded from https://www.cnic-n9portal.com/elibrary/. The infant’s first and last name and photo shall be included on the placard; d. After placing infants on their back for sleep, infants may then be allowed to assume any comfortable position. Infants are not required to be repositioned if they roll over on their own; and e. When infant classrooms are combined or when a back-up CDH provider is used, the same guidance described above applies for infants temporarily moved into a room or home other than their own. For example: If Marcus, assigned to Infant Classroom A, is capable of rolling over and is moved to Infant Classroom B for the afternoon, a placard identifying that Marcus is developmentally capable of rolling over must be placed on or above the crib Marcus is using during his stay in Infant Classroom B. 3. The use of blankets in cribs and pack-n-plays are no longer authorized in Navy CYP safe sleep environments. As an alternative to using blankets, one piece SleepSacks are authorized 3

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

and provided for all Navy CYP infants for use in safe sleep environments. Parents can opt to use the CYP-provided sleep sacks, provide their own compliant SleepSacks, or have their infant sleep only in current daily wear. a. Navy CYP Back is Best SleepSacks Wearable Blankets and Early Walkers by HALO Innovations are the authorized sleep sacks provided in CYP for use with infants 12 months of age and younger. Enclosure (2) provides additional information about sleep sacks. (1) An initial purchase of Navy CYP Back is Best SleepSacks in a variety of sizes will be centrally funded by CNIC (N926). This initial purchase and delivery to all CYP providing care for infants has been pre-arranged with HALO Innovations as an Enterprise Initiative; and (2) Future replacement of SleepSacks is a CYP responsibility. CYP are authorized to purchase two SleepSack Wearable Blankets (ages 6 weeks to 10 months) or Early Walker (ages 10 to 12 months) annually per infant. Enclosure (3) shall be used for all future replacements. b. If an infant has a medical condition that warrants the use of a SleepSack beyond the age of 12 months, the requirements under the medical exemptions section must be met within the provision of care; c. Only lightweight clothing can be worn under the sleep sack in order to prevent the infant from overheating; d. Programs shall ensure supervision by sight and sound as required and referenced below; and e. Programs shall communicate the new sleep sack requirement to currently enrolled families and new families enrolling in the program. 3. Swaddling is prohibited in all Navy CYP. Evidence has shown that swaddling can increase the risk of serious health conditions, to include dysplasia of the hip and overheating. 4. An infant may be offered a pacifier when they are placed in the crib or pack-n-play to sleep. a. Pacifiers shall not have any type of attachment; b. Pacifiers shall not be attached to the infant’s body, the infant’s sleep sack or clothing, or to the crib or pack-n-play at any time; and c. If the infant falls asleep and the pacifier falls out of the infant’s mouth, it must be removed from the crib and not reinserted.

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

5. Soft or loose bedding shall not be used in infant sleeping environments. This includes, but is not limited to; sleep positioning devices (unless medically approved, in writing, and noted on the Back to Sleep Placard), bumper pads, pillows, flat sheets, blankets, quilts, comforters, sheepskins, etc. Infant active environments may include a rug or other soft furnishing provided during play, including a cushion, mat, or quilt on the floor; however, consistent and careful supervision of all infants and children shall be adjusted appropriately for differing ages and abilities accordingly. The CYP professional must show awareness of the whole group whether working with one infant or an entire group. 6. Toys, including but not limited to dolls, animals, mobiles, and other types of play equipment that are designed to be attached to any part of the crib or pack-n-play, shall not be used or placed in or on the crib or pack-n-play. 7. Infants shall not sleep in a bouncy chair, infant seat, highchair, chair, car safety seat, sofa, or any type of furniture that is not a CPSC safety-approved crib or pack-n-play. Infants, who fall asleep in or on any of these types of devices must be removed immediately and placed in their assigned crib or pack-n-play in the back to sleep position. 8. Infants who fall asleep on the floor must be moved to his/her assigned crib or pack-n-play immediately and placed in the back to sleep position. 9. Infants who arrive at the program asleep in a car safety seat must be removed from the seat immediately by the parent/guardian or CYP professional. The infant shall be placed in their assigned crib or pack-n-play in the back to sleep position. MEDICAL EXEMPTIONS TO BACK TO SLEEP REQUIREMENTS: 1. Parents of infants with medical conditions which warrant an exception to this guidance must provide a written statement by a physician indicating the nature of the medical condition and include detailed sleeping instructions related to the provision of care. The medical statement must be obtained prior to the accommodation. The following guidelines must be followed: a. Complete the Inclusion Support Information and Referral Form. This shall be submitted to the Inclusion Action Team along with the physician’s statement for review and recommendations; b. Establish an Inclusion Support Plan (ISP) based on the guidance from the infant’s physician, which shall include: the prescribed sleeping instructions for the infant, any additional guidance on the frequency of adult supervision (at a minimum of every 10 minutes), and any specific signs of distress when monitoring of the infant while using an alternate sleeping position. CYP professionals must be trained in making the appropriate accommodation as indicated in the established action plan; 5

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

c. Store a copy of the ISP in the Support Binder located in the classroom or in the infant’s file in the CDH home to protect the confidentiality of the infant’s medical information and to ensure that the information is readily accessible; d. Display the Back to Sleep placard indicating that the infant has an approved accommodation to the required back to sleep position; and e. Develop policies and procedures for responding to emergencies. All CYP professionals caring for infants with sleeping accommodations must have an awareness of the medical condition and be trained to respond in the event of an emergency. SUPERVISION REQUIREMENTS IN CYP: 1. Infant sleeping areas in all CYP serving infants shall be well lit and co-located with classroom or home activity areas so that line-of-sight adult supervision is maintained at all times. a. CDH providers shall be vigilant and keep young infants and toddlers in sight and sound at all times with the exception of short breaks for taking care of personal needs within the home (e.g. taking a bathroom break). When taking care of personal needs; providers must be able to hear all children and must check each sleeping infant/toddler immediately upon returning from taking care of personal needs. CDH providers must be able to hear all children when taking care of personal needs and shall not leave children engaged in high-risk activities unsupervised. Eating and water play are examples of high-risk activities. 2. When line-of-sight supervision is augmented by mirrors in a CYP facility, the mirrors are only used as an additional supervision aid, not as primary devices to substitute for line-of-sight supervision. 3. The lighting in the classroom or home must allow the CYP professional/provider to see each infant’s face, view the color of the infant’s skin, and check on the infant’s breathing, and view placement of the pacifier, as any changes may indicate signs of distress. 4. At least one CYP professional in the classroom must be able to see (if not in the direct lineof-sight, then by looking up or slightly adjusting one’s position) and hear the infants in their care at all times. 5. CYP professionals shall check each sleeping infant at a minimum of every 15 minutes. For infants who require an alternative sleep position, CYP professionals shall check the sleeping infants at a minimum of every 10 minutes. Checking on the sleeping infant means that within the designated time increment, a CYP professional shall walk over to the crib or pack-n-play to assess the sleeping infant both visually and physically (by touching the sleeping infant) to detect signs of distress, discomfort including overheating or chill, or need for adult assistance. 6

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

6. Beginning when an infant is able to hold their head up for a short time, CYP professionals shall provide supervised “tummy time” when infants are fully awake to ensure infants develop upper body strength and head control, supporting physical development. a. As the infant’s muscle strength allows, the CYP professionals may begin to conduct “tummy time” in sessions of three to five minutes while the CYP professional is sitting on the floor next to the infant(s), interacting with the infant(s), and ensuring infant(s) are not in distress. Under no condition will an infant be left unattended (out of arms reach) on their stomach during tummy time; b. If an infant is in distress, the CYP professional must reposition the infant’s body or end the tummy time session; and c. If the infant falls asleep during tummy time, the infant must be moved to his/her assigned crib or pack-n-play immediately and placed in the back to sleep position. TRANSITION FROM CRIB TO COT: 1. A child’s size and developmental level should be the deciding factor in determining when an infant will transition from a crib/pack-n-play to a cot. Transitioning an infant to a cot too early or delaying transitioning an older, more active infant to a cot can both increase the risk for injury to the child and compromise their safety. a. When an infant becomes tall enough (36 inches) or mobile enough to reach crib latches or potentially climb out of a crib/pack-n-play, the infant should be transitioned to a cot; and b. Using the guidance provided and based on observations of the individual infant, the CYP professionals, in collaboration with the parents, should determine when it is developmentally appropriate for the infant to transition to the cot. TRAINING: 1. All CYP Professionals shall be trained on Safe Sleep Practices during orientation using the DOD online training Safe Sleep Practices for Caregivers: Reduce the Risk of Sudden Unexpected Infant Death (SUID). 2. Training and Curriculum Specialists are required to establish one account for the program which can be accessed by all CYP professionals required to take the training. 3. The training and account registration can be found at: http://extension.psu.edu/youth/betterkidcare. 7

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

a. Log onto http://extension.psu.edu/youth/betterkidcare; b. On the left menu bar, click "On Demand Web Lessons"; c. When prompted to sign in, the Training and Curriculum Specialist should enter a work email address and select “No, I am a new customer” to create a new for account for their program; d. On the next page, select “New Customer”; e. When prompted, complete the Better Kid Care Profile using generic information as this is an account that will be used by many CYP professionals; f. Where it requests birth date and last five numbers of SSN, programs shall use the below information: (1) Birthdate: 2/02/22 (2) Last five numbers of SSN: 22222. g. Once registration is complete, the program will be prompted to log in to the newly created account with its established username and password; h. Upon logging in, scroll down the list of trainings and select the title of the lesson: Safe Sleep Practices for Caregivers: Reduce the risk of SUID. (Note: this is a free session. Payment is not required); i. Training and Curriculum Specialists shall ensure this information is shared with all CYP professionals who are required to complete this training; and j. Training shall be documented on the CYP professionals’ appropriate Individual Development Plan (IDP) and in the Child and Youth Management System (CYMS) training module. 4. Annual refresher training shall be provided only to those CYP professionals assigned at a CYP serving infants and shall include topics such as but not limited to: a. Reducing the Risk for SIDS in CYP; b. Using infant sleep sacks (process and procedures); and

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CHILD AND YOUTH PROGRAMS Prevention of Sudden Infant Death Syndrome Guidance (Revised December 2015)

c. Active and direct supervision and monitoring practices. Proper supervision strategies must include, but are not limited to, positioning of CYP professionals during sleep time and being attentive to signs of distress. 5. Programs shall ensure training and resources on SIDS and safe sleep environments are provided to families during new parent orientations and as part of the Parent Participation Plan. AVAILABLE RESOURCES: • Back to Sleep Placards can be found at the E-Library at: https://www.cnicn9portal.com/elibrary/ • Additional information and resources on reducing the risk of SIDS can be found at the following sites: 

AAP provides a free online course on safe sleep practices: http://www.healthychildcare.org/sids.html

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Consumer Products and Safety Commission: http://www.cpsc.gov/nsn/safesleep.pdf

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National Institute of Child health & Human Development: http://www.nichd.nih.gov/sids/Pages/sids.aspx

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National Child Care Information and Technical Assistance Center: 1-800-616-2242 or http://nccic.org

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National Resource Center for Health and Safety in Child Care: 1-800-598-KIDS or http://nrckids.org

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HALO® SleepSack® Wearable Blanket and HALO® SleepSack® Early Walker Fact Sheet

SLEEPSACK WEARABLE BLANKET

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Replaces loose blankets in the crib that can cover baby’s face and interfere with breathing Sleeveless design helps reduce the risk of overheating A roomy “Hip Healthy” sack to promote healthy hip development “Back is Best” embroidery to remind all caregivers to put babies to sleep on their backs Inverted zipper for easy diaper changes Premium fabrics – never any added chemicals Sack design helps lessen the likelihood for baby’s legs to get caught in crib rungs Easy laundering Used in hospital nurseries nationwide

SLEEPSACK EARLY WALKER

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Use over regular sleepwear to take place of loose blankets that can interfere with breathing Unique foot openings for greater mobility while babies are awake, but keeps feet covered and warm while sleeping Warm and cuddly fabric helps baby sleep better at night Sleeveless to allow for ease of dressing and freedom of movement Unzips from the bottom for easy diaper changes Generous sack design allows room for kicking, but cannot be kicked off so baby stays warm all night Premium fabrics – never any added chemicals Keeps baby from trying to crawl out of their crib Easy laundering