"That's why I'd never put my child in daycare."
Because nearly every story about daycare deaths goes viral, every few weeks the internet is full of people making this judgment of the family who has recently expressed tragedy. Such comments imply that whatever fates befell the children in these stories are the fault of their parents for placing them into daycares, which are often portrayed as decrepit and dangerous.
There is certainly more that can be done to ensure children are safe when outside their parents' care, just as there is more to be done to ensure children are safe when in their parents' care. But to lay the blame on grieving parents for placing their children in daycare is the wrong reaction, leading parents who choose daycare feeling fear and shame about a perfectly reasonable choice.
Mercifully, accidental deaths are extremely rare at daycares, and deaths due to abuse and neglect are rarer still. The available literature about daycare-related deaths shows how infrequent these incidents actually are, and suggests strategies for how to make them even less likely than to happen in the future. Although this information is likely to halt the flood of internet commentary, perhaps it can help parents can make better-informed choices about their children's care.
"Daycare" is any care provided during the day that is not from the child's legal guardians. It is a catch-all term for child care that takes place in a variety of settings: a child-care center, a private home, or even in the child's own home in the case of a nanny. Nearly all child care centers and even many private home daycares are licensed. "Unlicensed" can be a confusing term, suggesting that a daycare provider is acting illegally, but many states do not require licensure for certain types of caregivers.
Daycares and SIDS
One way to determine the safety of daycares would be to think about how much time children spend in the care of others versus in the care of their parents, weigh the death and injury rates among the daycare-using and non-daycare-using populations to determine whether one scenario is safer than the other. That data does not exist for all types of injuries or deaths, but some types of deaths, such as SIDS deaths, are nationally recorded. That data is a starting point for studying daycare safety.
One study of sleep-related infant deaths that often resurfaces when a child dies at daycare is this study of SIDS in daycare centers. The researchers estimated that, for babies who spend around 40 hours per week in daycare, about 7% of SIDS-related deaths should happen in a daycare setting. But they concluded that over 20% of SIDS-related deaths in 11 states between 1995 and 1997 occurred in daycare settings, a finding which suggested that daycare settings were less safe than home care.
One problem with this study, however, is that 17% of the SIDS deaths reported during the researchers' timeframe were excluded because the researchers could not determine the location of death. Although the researchers indicated that the 17% of excluded cases contained similar demographic diversity of the main sample, those 17% of deaths would be really important to making determinations about the likelihood of death in a childcare setting.
Another problem was the length of time that researchers assumed children were in child care settings. The researchers estimated that children spend 40% of their time (a 40-hour work week) in daycare, a figure they realize may not be appropriate, given that many parents work longer hours. Both the excluded cases and the assumption about hours spent in care make it difficult to derive sound conclusions from the data.
But these two factors are perhaps less important than the largest problem with the study: how it has been interpreted. The researcher's finding is used as evidence that child care centers are more dangerous than home care. The study did not draw a specific conclusion about child care centers, but rather all forms of care outside the home. The researchers found that 60 percent of the SIDS deaths in out-of-home care were at a family member's home. Daycares run out of private homes represented 12.2% of SIDS deaths. Child care centers, the image that most often comes to mind when we think "daycare," represented just 2.6% of SIDS deaths.
Of course, the 17% of cases excluded from the original sample could make these numbers much different. But it appears that SIDS deaths were less likely to occur in child care centers than in other care arrangements. Given that many of the children in the sample were found on their stomachs, the researchers suggest one reason for the higher incidence of SIDS deaths among infants in child care is that some caregivers are less educated about SIDS risk than others. This helps explain the difference in SIDS death rates in private homes, where licensure is not always required versus child care centers, where licensure is required and often includes SIDS awareness training.
A question of timing
For 99 of the cases in the above study, researchers also had information about the length of time children had spent in daycare at the time of their deaths. They found that for this small sample, one third died during the first week of care, and one sixth died on the first day of care.
What the study fails to consider is when SIDS is most likely to occur: between age 1 and 4 months. Because these deaths occur at roughly the time that their parents return to work, children who die from SIDS in daycare are used as evidence for the safety risks posed by daycares. But what if we are looking at correlation, not causation? Researchers examining the relationship between preterm infants and SIDS found that very preterm babies who die of SIDS tend to die at around 20 weeks of age, while babies who were early term and full term die earlier, at about 15 or 14 weeks, respectively. 14 weeks, 15 weeks, 20 weeks: those ages all suggest that the most likely time of SIDS will occur after a parent has gone back to work, given that our current national legal family leave is 12 weeks and roughly a quarter of women who return to work after having a baby do at 8 weeks.
Daycare deaths caused by abuse or neglect
Parents concerned about abuse or neglect by a daycare provider can take small comfort in the fact that parents, more than any other group, are the most likely perpetrators of such violence against children. According to a CDC report, in 2014, parents were responsible for 79.3% of fatalities for children through age 4.
"Nonparents" were responsible for 15.7% of those fatalities, but "nonparents" is an extremely broad category including, among others, both extended family members and daycare workers. It appears clear, then, that parents are more likely to be the perpetrators of lethal abuse or neglect than daycare providers.
But that's not what we think about when we read about daycare-related deaths in the news. In his sensationally-titled "The Hell of American Daycare," Jonathan Cohn profiles a mother whose daughter died after being trapped in a house fire at a family daycare. It's a tense, slowly-unfolding, horrifying piece, the kind that makes you hold your breath as you scroll, hoping the story isn't going where you think it will. But of course, it does, and readers are further drawn into the fire and its aftermath, as well as Cohn's interviews with daycare inspectors, one of whom would not trust her own children with more than 20% of the daycares she has visited.
Beware the solitary news story
Daycare deaths like the one Cohn profiles are, from a clicks-and-shares perspective, "perfect" news stories: they offer single, poignant, terrifying stories that burn into our memories and stoke our greatest fears. These kinds of stories can lead us to an inflated sense of risk about daycare, because we're less likely to see a news report that reports on how a daycare center is doing everything right and all the kids are happy and healthy.
We're also likely to read such stories as sort of coded messages about the parents whose children die in daycare. Because those deaths happen disproportionately at lower-cost sometimes unlicensed centers, there are issues of race and class involved that can lead readers to assume that the parents have done something wrong, that they haven't done their due diligence in checking out the child care center or that it was their own behavior that required them to need child care in the first place.
Parents who read these sorts of stories should not interpret them as a indictment against daycare more broadly, but instead as an opportunity to identify systemic problems with daycare. The widely different rates of SIDS-related deaths in different types of daycare situations is one such example. That SIDS deaths appear to be higher in private homes than in daycare centers suggests that parents who wish to use in-home care should check for common risk factors associated with SIDS (such as smoking) and confirm that their providers are aware of current infant sleep guidelines.
Beware the solitary caregiver
Stories about daycare deaths start to make daycares themselves look dangerous, simply because all daycare deaths have one thing in common: the deaths occurred during daycare. But looking at these stories more closely, it's possible to identify other common variables. Another feature of these stories is a caregiver left alone with children, or, as was the case with the case profiled in Cohn's article, a caregiver who left the children alone.
Many states have required infant-caregiver ratios that, when followed, ensure that no single employee is overwhelmed with watching for too many children at once. Daycare.com provides state-by-state licensing requirements for caregivers, including the infant to caregiver ratios required by each state. For 30 states, as well as the District of Columbia, the ratio for infants to caregivers is 1:4; that is, there is one adult for every four children. In 10 more states, that ratio is 1:5. In Arkansas, Georgia, Louisiana, New Mexico, and South Carolina, the ratio is at its highest: 1:6. Kansas, Hawaii, Maryland, and Massachusetts share the lowest infant-caregiver ratio, which is 1:3.
Many states also have maximum class sizes with adjusted ratios. For example, Wyoming has a 1:4 ratio for infants, but a maximum class size of 10. Classrooms with 10 infants require 3 caregivers, shrinking the ratio below the 1:4 requirement for smaller classrooms. Other states permit slightly different mixes of children, depending on their ages. Idaho, for example, works on a points system, which assigns points to different age groups (2 points for children under 24 months, 1.5 points for 2-3 years) and allows each caregiver a total of 12 points, which would translate into an infant-caregiver ratio of 1:6, but could also mean 4 infants and 4 five-year olds.
In many states, the infant-caregiver ratios are different for "family care" situations, which means that children are taken care of in a private home rather than a dedicated center. Many states don't require licensure for family care until a certain number of children are in the home. In 12 states, licensure is required for even one child. In Arkansas, Indiana, Iowa, Mississippi, New Jersey, North Dakota, and Virginia, licensure isn't required until there are 6 kids. In South Dakota, it's 13 kids. And many states do not consider the provider's own kids in the regulation threshold.
When interviewing a daycare provider, it may not be enough for parents to ask whether or not a center adheres to that legal caregiver ratio, as it's unlikely a provider would volunteer that the center was acting illegally or irresponsibly. Instead, it might be more valuable for parents to ask what the back-up plan is when a caregiver has to be absent. How does the daycare provider ensure the appropriate ratios are met? Are children sent home? Are substitute caregivers called in? Who are the substitutes? A daycare provider with answers to these questions is less likely to be in charge of too many children at once, ensuring that all of those children can be safely cared for.
This piece originally appeared on Parent.co.