kdheks

1. http://www.kdheks.gov Our Vision – Healthy Kansans Living in Safe and Sustainable Environments

2. Death in Kansas Child Care • Child Care Death Scenarios • Child Care Death Data • Patterns Regarding Care • Serious Injuries in Relation to Risk of Death • What We Can Do Now Governor’s Child Health Advisory Committee October 24, 2008

3. Child Care Death Defined A child care death is defined as a death to an individual, ages 0-17, from any cause wherein the child was in the care of a regulated home or facility at the time of death or at the initiation of the events that resulted in death regardless of the place of death.

4. Child Care Deaths • 2nd day of care: 3 ½ month old child placed for nap in playpen on stomach; found face down, unresponsive and limp; sleep positioner and blanket used in playpen. 60 minutes between checks • Cause of Death: SIDS • 10th day of care: 1 ½ month old child placed on side for nap in playpen in basement; provider went to doctor and teenage daughter was left to care for children; infant found unresponsive on stomach. 65 minutes between checks • Cause of Death: SIDS • 1st day of care: 3 month old child found on stomach unresponsive while napping; provider had more children in care than allowed by the license. 20 to 30 minutes between checks • Cause of Death: SIDS

5. 12th day of care: 2 month old child placed in bouncer on adult bed with pacifier and mesh cover; found unresponsive. 188 minutes (3 hrs 8 minutes) between checks • Cause of Death: SIDS • 6 month old child placed on adult bed to nap; provider took medication and slept on couch; adult did not know child was on bed and took nap on bed; infant found wedged between mattress and footboard. 60 minutes between checks • Cause of Death: Positional Asphyxia • 13 month old placed in car seat with only middle strapped tightly around mid-section; carrier was placed in laundry room and child found slumped over, lips blue, and not breathing. 150 minutes (2 ½ hours) between checks • Cause of Death: Strangulation COMMON THREADS WITH EACH CASE? PATTERNS EMERGING? CONCERNS REGARDING CARE?

6. Doll Re-Enactment: Wedging Wedging: The asphyxia of a person by their own weight compressed between two hard surfaces. During 2007, two infants were placed on adult beds and fell between the mattress and footboard, cutting off breathing

7. Doll Re-Enactment: Positioning Compromises Breathing Placed Position Found Position Positioning: Side sleeping is not considered safe, even with a positioning device; infants often roll to their stomach and do not have strong enough neck or stomach muscles to adjust to the position and turn their head. Breathing is compromised.

8. Child Care Death Data • KDHE contracts with local health departments to conduct inspections and provide regulatory services for approximately 8,100 child care facilities • More home based facilities (n=6,921 or 85%) than child care center facilities (n=1,262 or 15%) • More capacity in child care center facilities (n=75,551 or 55%) than home based facilities (n=59,533 or 45%) • Child Care Surveyors report child care deaths to KDHE and conduct investigations which involve an on-site visit, joint investigation with other agencies, contact with witnesses, and obtaining final reports • Tracking system and new investigation procedures were implemented during 2007 • Data and circumstances surrounding deaths reveal patterns regarding the care of children • No other agency or organization collects information as specific in regard to child care deaths

9. New Procedures & Tracking • Implemented new procedures in order to • Guide investigations of serious injury (requiring medical attention) and death in child care • Gain additional information for sudden, possibly unexplained deaths of children under 18 months • Ensure uniformity in the collection and documentation of information obtained in such investigations across the State of Kansas (new injury and death investigation form modeled after CDC SUIDI form) • Facilitate the development of standardized tracking of data in the Child Care Licensing & Registration Information System (CLARIS) • Recommend changes in regulation and enforcement that could reduce the risk of injury and death

10. What We Track • Identifying information for facility and child • Circumstances surrounding death or injury • Staff and children present (capacity) • Medical attention received • Other agencies involved in investigation • Official cause of death (per DC) or injury • If infant death (0 to 18 months), additional information is collected

11. Death in Regulated Child Care • Majority of child death occurs in children less than 1 year of age that are newly enrolled • Deaths occur across the state, urban and rural areas • Seemingly healthy infants die in care during sleep • Majority of deaths determined Sudden Infant Death Syndrome (SIDS) • Unexplained infant deaths are not always SIDS

12. Deaths in Regulated Care RDCH: Registered LDCH: Licensed GDCH: Group CCC: Child Care Center SAP: School Age Program FFH: Family Foster Home RES: Residential Center IL: Illegal Care The chart reveals 14 deaths in 2007 (12 infants) and 5 deaths so far in 2008 (4 infants). Death in family child care is more common than center death (Kansas and national). The highest number of 2007 deaths occurred in Registered homes (not inspected).

13. Infant Death: Sleep Position/Location Found Position: 5 out of 8 placed on their backs* were found unresponsive on their stomachs, 3 infants were found on their backs as they were initially placed, and 1 was found wedged; 1 out of 3 infants placed on its side was found on its stomach; the unknown placement was found wedged. Infants placed on their back were most often found on their stomachs. *self-reported by caregiver

14. Child Care Practices Related to Death Most common cause of death is SIDS, which by definition is NOT preventable, but we CAN reduce the risks. • Supervision • Average time between checks is 48 minutes, only 2 of 12 checked 15-20 minutes as recommended; 1 to 3 hours went by in several cases • All infants in day care homes were in back bedrooms with doors closed/partially closed or in a lower level at time of death • Inappropriate sleep location and/or surface • 50% of infants (6 of 12) that died in 2007 were napped on adult beds or other baby seats (EX: bouncer) instead of an approved crib or playpen; regulation requires nap or playpen for children under 18 months • Inappropriate sleep position (stomach or side sleeping) • 42% (5 of 12) infants that died in 2007 were placed on their side or stomach rather than on their back as recommended for safe sleep • 75% ( 9 of 12) napped inappropriately, either location or position • Unaccustomed sleep position? (we do not have information regarding sleep position at home versus in care or whether or not providers communicate with parents regarding infant sleep practices) • Others ?

15. What Responsibility Do We All Have When it Comes to Child Care? “For by the time the child reaches six months of age, his primary caretaker becomes a crucial and irreplaceable person who must be there…” Source: Karen, R. (1994). Becoming Attached: First Relationships and How They Shape Our Capacity to Love.

16. Governor’s Child Health Advisory Committee Mandate: “Advise the Governor and the Kansas Department of Health and Environment (KDHE) on issues involving children, including…” Positioned to impact child care law and regulation, educate on safe child care practices, and reduce the risk of harm to Kansas children while in out of home care.

17. The majority of infants die early in care (newly enrolled) • Infants are not consistently placed on their backs • Infants are not consistently placed in approved cribs or playpens • Infants are not placed without bedding or soft items • Infants are not supervised during sleep (within hearing distance, on the same level of the home, visually checking every 10 to 20 minutes) • Providers lack training in reducing the risk of sudden infant death or unintentional suffocation Wrap Up: Infant Death in Child Care • No providers caring for children that died in 2007 had acquired training; the caregiver that placed a child in a car seat during 2008 reported she had attended training • Only 31% (5 of 16) had safe sleep brochures • 80% (4 of 5) caregivers with information on safe sleep napped as recommended

18. Serious Injuries In Child Care…Near Misses? • Under current regulations, child care homes and facilities are not required to report serious injuries to the health department or KDHE (only school age programs report), making it impossible to accurately track total number and types of serious injuries • Pursuant to KAR 28-4-127(e)(2), programs are required to immediately report to parents • Most common type of injury since tracking began is a fracture; recent data reveals young toddlers and preschool age children are at greatest risk

19. Bruising By Provider’s Hand 19 months old

20. 28 Human Bites – 1 year old

21. Human Bites – 2 months old

22. Burns & Blisters – 13 months old

23. 2008 Injuries By Type & Program *as of 5/5/2008 KDHE has seen a great increase in the number of injuries occurring in homes to very young children (infants and young toddlers); centers have more injuries to older toddlers and preschoolers.

24. What Can KDHE Do Now? • Continue collecting data and analyze for emerging patterns • Increase awareness of parents, providers, and public regarding recommended child care practices that protect children • Collaboration with agencies and organizations in Kansas: Vital Statistics, Child Death Review Board, Safe Kids, SIDS Network • Public Education: Safe Child Care Task Force (KS Chapter AAP, SIDS Network, KACCRRA, Safe Kids, KDHE, Child Death Review Board, KS Action for Children, parent and family advocates) • Provide data and case information to the Child Care System Improvement Team to guide regulation revision • Ensure the health and safety of children is protected while in out of home

25. Contact Information Rachel Berroth, MS ECE Regional Administrator Early Care & Youth Programs Child Care Licensing & Registration Program Kansas Department of Health and Environment Curtis State Office Building 1000 SW Jackson Street, Suite 200 Topeka, KS 66612 785.296.1270 rberroth@kdhe.state.ks.us http://www.kdheks.gov/kidsnet

26. http://www.kdheks.gov Our Vision – Healthy Kansans Living in Safe and Sustainable Environments