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Information for Childcare Providers on Ways of Preventing SIDS

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Thank you for your recent inquiry about SIDS.

When the incident occurred at my day nursery, my knowledge of SIDS was largely limited to what I had read in the newspapers. The mere thought of SIDS occurring at my day nursery was a frightening prospect. When it happened (in July 1995), the infant was taking a nap in an 8-mat room forming a circle with other infants under one year of age. The caregivers who were present in the room did not notice for a long time that the child's breathing had stopped.

It was a warm summer day. The room was quieter than usual. The infant in question had been sleeping face down. He had taken a plenty of milk and played cheerfully before taking the nap. There were no visible signs of an illness.

We thought the child was sound asleep. We were shocked to realize that his breathing had stopped so quietly--far quieter than we could ever have imagined.

As soon as we realized that he was no longer breathing, artificial aspiration was resorted to in a frantic effort to revive him--by the nursery caregivers, the ambulance technicians, and the hospital staff--all to no avail.

I am truly sorry and remorseful that we could not detect the stoppage of breathing immediately after it happened. In my ardent desire to prevent others from experiencing similar sorrow and guilt, I am resolved to do what I can to help promote SIDS prevention activities.

1. SIDS Occurs Suddenly During Sleep; Breathing Stops Very Quietly

At present, there are no known ways of completely preventing occurrences of SIDS. Having experienced SIDS, we believe the following five points are critical for lowering the risk of SIDS, discovering the warning signs of SIDS as early as possible, and effectively coping with actual occurrences of SIDS. I strong recommend that all childcare practitioners adopt these measures.

* Do not place an infant face down to sleep.

* Place the blanket below the neck of the baby; avoid covering part of the face.

* Do not overheat the infant's surroundings.

* Use a timer to check the infant's breathing every 10 minutes; at the same time, check the body by touching it.
This is for both confirming that they are alive and for stimulating their senses (in order to prevent imminent occurrence of SIDS.)

* Be able to apply artificial respiration. (Get training in CPR methods.)

Listed below are what we practice at our nursery to lower the risk of SIDS. Eliminating the suspected causes of SIDS one by one helps minimize the chances of SIDS occurrence.

* We place infants down for sleep on their backs. (If they fall asleep prone, we turn them over to the supine position.)

* We make sure that the blanket does not cover part of a sleeping baby's face. This is to (1) avoid the infant's own exhaled air to get trapped, and (2) make it easier for the caregiver to observe the infant.

* We do not use soft bedding, and use a light summer blanket for covering the body.

* We do not darken the room where infants take a nap so that we can easily observe their facial expressions. We use a mirror and a see-through door so that the caregiver can observe the sleeping babies. (We pull curtains only when we put infants to sleep.)

* We pay a close attention to the air temperature in the rooms where babies sleep, making sure we do not overheat their sleeping environment. We had additional air conditioners installed. There is a wall thermometer in each room.

* We cannot ascertain if a baby is breathing by merely observing his or her face close by. Therefore, we use a timer to make sure the baby is breathing (alive) once every 10 minutes. This is a sure-fire method, and gives us a peace of mind. In my nursery, all sleeping infants are checked in this manner regardless of their age. We confirm their vitality by listening to their breathing, and closely observing the pulsatory motion below their ears. Additionally, we pass a hand over their faces lightly and touch their bodies. This is for both confirming that they are alive and for stimulating their senses (in order to prevent imminent occurrence of SIDS.) We recommend that you follow these measures closely, especially for infants under two years of age.

* Periodic confirmation of breathing leads to an early discovery of an imminent SIDS attack and therefore prevention of a SIDS death.

2. About Prone Sleeping

Although the exact cause is unknown, it is a fact that babies who sleep prone have a significantly greater risk of dying from SIDS. One hypothesis is that prone sleeping leads to a deeper sleep, which in turn reduces the baby's reflexes. Furthermore, the caregiver cannot observe the face of an infant who sleeps prone; very close attention should be paid to the face when a baby is fast asleep.

3. Steps You Should Take When You Find an Infant Is Not Breathing

Immediately tap the infant on the back to give a stimulus. If the breathing is not restored, call loudly for an ambulance. With your finger, clear foreign matter such as undigested milk from the mouth of the infant. Open the infant's airway, place your mouth over the infant's mouth and nose, and breathe into the infant's mouth about 30 times per minute, gently but forcefully enough to cause a noticeable swelling of the chest each time you exhale. Continue breathing until medical help arrives. (I recommend that you get training in CPR methods given by fire stations and other agencies.)

4. SIDS Is Defined as Sudden Death of Infants Under Two Years in Japan, Under One Year in the U.S.

Eighty percent of SIDS occurs in infants under 6 months of age. You should therefore be especially careful about this age group, but you must remember that it can and do happen to older infants.

5. What We Explain to Prospective Customers Visiting Our Nursery for Information, and to New Customers

We ask all new customers to instruct us in writing whether they allow their children be put to sleep face down. (Even though the parents do not object to the prone sleeping position, we take care not to allow this sleeping position.)

* We convey to all customers, both verbally and in writing, that the insurance policy we carry (institutional liability insurance for day-care facilities) does not cover cases of children becoming ill or injuries caused by fights among children. (It is imperative that customers are fully aware of the limits of your insurance coverage.)

Note: Coverage varies somewhat between insurance companies. It is very important that you yourself are fully informed of the nature and scope of your policy's coverage.

6. If SIDS Should Strike Your Nursery

* The nursery staff should place confidence in the head (owner/operator) of the nursery, and follow his or her instructions in dealing with the situation.

(This is especially true of nurseries where no specific caregiver was assigned to the SIDS victim. In such a case, there may develop a lack of unity between the head and the nursery staff. It is important that care should be exercised to avoid this unfortunate outcome.)

* The nursery staff including the head naturally experience a trauma arising from confusion, grief, and sense of guilt toward the family of the SIDS victim. It should be kept in mind, however, that the family's grief is even more intense. Everyone at the nursery, therefore, should respect the feelings of the family above anything else, and deal with them in all sincerity.

* Never hide facts from the parents. They have the right to know what happen to their children at the nursery, and the nursery has an obligation to honestly disclose the facts to them.

* The caregiver who had been taking care of the infant when the death occurred also experiences sorrow and guilt. Seek professional counseling so that he or she can find comfort and support.

** It is important that all the members of the nursery staff make the habit of reading Guidelines published by the SIDS Family Association Japan, and hold periodic sessions to discuss how to cope with SIDS.

7. The Question of Insurance

At present, there are no insurance policies which non-licensed day nurseries can buy in order to provide coverage of liability arising from SIDS cases. Licensed day-care centers, by contrast, can avail themselves of mutual liability insurance provided for by the National Stadium and School Health Center of Japan Law.

There is no difference between licensed and non-licensed day nurseries as far the quality of lives of the infants entrusted to their care is concerned. Since the year before last, I have contacted a large number of life and non-life insurance companies to see if they would be willing to create a policy for non-licensed day nurseries (including baby-sitting businesses) across the country. Thus far, this request has been rejected by every one of them, stating that such a policy would be difficult under present conditions. (I have not abandoned the search for an insurance company which would be amenable to the idea.)

It is far from my thought that I could compensate for the loss of precious life with money; I sincerely hope that everyone understands this point. Nothing would give me a greater joy than being able to return the child to his family, alive. Knowing it is an impossibility, my mind is filled with tremendous remorse. To ease the pain in my heart, I wish I could at least offer the bereaved family a gift of money in token of my sympathy and apology. It is difficult for me to express in words exactly what I have in mind, but I hope you get the thrust of what I am trying to say. My heart is filled with a sense of guilt toward the family.

8. On the News Media (Newspapers and Television Stations)

When SIDS struck our nursery, a large number of newspaper reporters descended on it at an unbelievable speed. We were also besieged with phone calls from television stations seeking information.

Media reporters tried to gather materials on the case without regard to the fact that the nursery staff were busy with daily childcare routine. Responding to the questions of media reporters in the midst of police investigation of the death scene and surrounded by a large number of infants being cared for would be hazardous and next to impossible.

We therefore kept our doors locked to visitors. Being at a loss as to what to do, I asked a police officer how we should deal with media reporters. His suggestion was to tell them to direct their questions to the police, which we did.

Reporters also chased some parents--those who came to the nursery to pick up their children--and interviewed them, willy-nilly, who knew nothing about the SIDS incident. I was truly sorry for what happened, and didn't know how to apologize to my patrons. I wished that media reporters, in doing their jobs, had been more considerate of the state in which the nursery was in, and the inconvenience they might have caused to our patrons and neighbors.

Some newspapers placed phone calls to the Childcare Section of the city and even the Ministry of Health and Welfare to collect news materials on my day nursery.

On the next day, only one newspaper published an article on the SIDS case at our nursery. To my astonishment, it read as though someone at the nursery volunteered information in an interview. It also specified the cause of death, which even the police did not know at that time. This article was enough to make me distrustful of news media.

I made a phone call to the paper to express strong objection to the content of the article, but it was skillfully dodged. I now realize that I should have gone to their office and protested face-to-face, instead of doing so by phone.


I would like to stress that the various points I raised in the above account relate to the events that took place in my day nursery and how I have dealt with them. Other childcare practitioners having a similar experience may have interpreted and reacted to it differently.

I dream and hope that there emerge in other prefectures day nurseries which can provide support on matters relating to SIDS. I believe that the operator of a nursery where SIDS occurred has at least one thing--no matter how insignificant it may be--that he or she would have done differently. I am convinced that ceaseless efforts on my part to collect such information and relate it to other day-care providers will help them lower the risk of SIDS at their establishments.

The words of the child's mother, who said "Please don't let my baby die in vain; please don't forget my baby's death." are written indelibly on my heart. I am resolved to do my utmost so that the infant did not die in vain.

One of my planned projects is to send information on how to prevent SIDS deaths, as well as copies of 130 Little Cries, to all the prefectures and municipalities across the country, which number approximately 830.

* The expenses of distributing copies of 130 Little Cries will be paid out of the cash contribution made by the Association For Studying Childcare Issues So That Keiichi-chan Did Not Die In Vain. Let me express my sincere gratitude to Mr. Kenji Azuma, Mrs. Hidemi Azuma, and other members of the association.

The large number of inquires about SIDS which I receive of late from childcare practitioners reveals the intensity of the profession's interest in this problem. This is truly gratifying.

The nature of these inquiries, however, makes me painfully aware of the paucity of information on SIDS made available to childcare practitioners by the Ministry of Health and Welfare. Adequate information is not conveyed to day-care facilities which are entrusted with the care of precious little lives. I think this is a very serious state of affairs.

I ardently hope that the materials I provide here prove useful to you. You are always welcome to visit my nursery for a study tour; please feel free to contact me.

** For the information on SIDS and insurance contained in this article, I am indebted to the following books: Sudden Infant Death Syndrome and Words for SIDS Families, and Accidents and Sudden Deaths in Childcare Facilities.

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