Tiny, white “onesies,” each bearing the name and

Why Aren’t We Outraged?
Children Dying in Child Care Across America
White Paper, July 30, 2012
Tiny, white “onesies,” each bearing the name and
age of a child in Missouri (who died in a child care
setting since 2007), hung on racks in the rotunda of
the state capitol in Jefferson City, Missouri, in
February 2012. Nathan, Bridget, Cooper and 51
other infants and toddlers died in child care and their
parents joined other advocates in a rally calling for
stronger child care laws.
Across the country other children were dying in child
care settings. Thirteen-month-old Lexie and 18month-old Ava died in Kansas. Seventeen-month-old
Warren died in Pennsylvania. Five-month-old
Madelyne died in Ohio. Juan was 22 months old
when he died in Indiana. Two-month-old Quale died
in Georgia. Two-month-old Dylan died in Virginia.
Four-year-old Jacob died in Texas. All of these
children and many more died in child care in the past
several years.
Just this month, three-year-old Benjamin Price died in
Texas in a hot child care van. Left for hours, he
succumbed to the heat.
Children’s Stories
Here are some of these children’s stories as reported
to Child Care Aware® of America (formerly
NACCRRA) who work with parents to strengthen
state and federal policy to better protect children.
Nathan’s death in Missouri was attributed to Sudden
Infant Death Syndrome (SIDS) in the medical
examiner’s report. What Nathan’s parents later
learned as part of an investigation was that the
provider had other infants asleep in the room. She
didn’t turn on the light when she placed baby Nathan
down to sleep in the portable crib so that she could
see his position. The sheet had slipped off the thin
plastic pad in the crib and when the provider placed
Nathan to sleep on his stomach, he tragically
asphyxiated on the plastic. Nathan’s provider did not
have liability insurance.
In Missouri, 3-month-old William “Sam” Pratt died of
alleged abuse in February 2009 at a family child care
home. The official cause of death was declared blunt
force trauma; however, the provider admitted to
police that she threw Sam down on a couch in
frustration. As of Spring 2012, the provider is awaiting
trial on charges of involuntary manslaughter and child
abuse resulting. The provider was not licensed, so
state regulators were unable to prevent her from
caring for children despite her criminal charges, and
she began caring for children soon after she bonded
out of jail. Sam’s provider did not have liability
insurance.
In February 2012 in Indiana, 22-month-old Juan
“Carlos” Cardenas drowned in a baptismal pool at an
unlicensed child care ministry (Longnecker, 2012).
His care was being subsidized with federal Child Care
and Development Block Grant (CCDBG) funds. In
Texas, 4-year-old Jacob died in a hot van, left for an
unknown number of hours in 103 degree F. heat.
When the provider who left him in the van was
arrested, her fingerprints were taken, which is how
Jacob’s parents learned about her extensive criminal
history. At the time, Texas did not require a
background check for child care workers that included
comparing fingerprints against state and federal
records.
As a result of Jacob’s death, his mother Avonda Fox,
fought for and won changes in state law to require
background checks for child care providers and extra
training for providers transporting children.
Unfortunately, a law alone is not enough. Benjamin
Price was left unattended in a van this month in the
hot Texas heat despite the law designed to protect
him. Clearly, beyond the law, states need to check to
ensure that the laws are followed, staff have
appropriate training and undertake checklists when
transporting children.
Eight-week-old Quale died on his second day of child
care, in a licensed child care setting in Georgia; he
was found in a pool of blood. In Virginia, 6-week-old
Dylan died in a church child care program; in Virginia
child care programs affiliated with churches are not
required to be licensed or regulated. The medical
examiner told Dylan’s mother that he was a perfectly
healthy baby who had passed away because he had
been laid on his stomach to sleep. Lexie and Ava,
toddlers in two different child care settings, both died
from injuries they received in family child care homes
in Kansas, which the police attributed to lack of
supervision. Five-month-old Madelyne died in an
unlicensed family child care home in Ohio where the
provider was ultimately convicted of multiple counts of
child endangerment and tampering with evidence.
Seventeen-month-old Warren died when he was
placed to sleep in an outdated and defective crib,
trapping his head and suffocating him in
Pennsylvania. More frequent inspections of child care
programs could serve to detect unsafe conditions and
prevent future tragedies.
reality, the cause of death is frequently unsafe sleep
practices in child care programs (HSRA, 2011).
Despite the ongoing national “Back to Sleep”
campaign, child care providers continue to put
children to sleep on their stomachs, with additional
items such as pillows and blankets, and on unsafe
surfaces such as couches and adult beds (Moon, R.,
Kotch, L. & Aird, L., 2006). In states such as Maine,
the number of Sudden Unexpected Infant Death
(SUID) fatalities has doubled in the last 10 years;
many of these deaths can be attributed to accidental
suffocation (Maine Department of Health and Human
Services, 2009).
SUID and SIDS play an important and tragic role in
child fatalities in child care. Half of the approximately
4,600 SUID deaths per year in the United States are
attributed to SIDS: the sudden death of an infant
which remains unexplained after a thorough
investigation, including a complete autopsy, an
examination of the death scene and a review of the
baby’s health history (HSRA, 2011). If any of these
steps are not completed, the death should not be
diagnosed as SIDS (National Center for the Review
and Prevention of Child Deaths, n.d.). While
numerous infant deaths are labeled SIDS, a more
accurate diagnosis may be SIDS caused by
Accidental Suffocation and Strangulation in Bed
(ASSB). Leading causes of ASSB include suffocation
by soft bedding or pillows, entrapment between a
mattress and wall or other surface, and strangulation
by crib railings. Death by ASSB-designated SIDS is
the leading cause of infant mortality and was on the
rise from 1990 to 2007 (HSRA, 2011). SIDS is
probably the most common cause of child fatalities in
child care programs, and its incidence can be
reduced.
While most children may be safe in child care, these
tragedies should be a wake-up call to policymakers to
ensure that children are not left to chance.
Private Tragedies
Nearly 11 million children are in child care programs
across the nation, including child care centers, family
child care homes and in-home child care (the child is
cared for in his/her own home by someone other than
the parents) (Hansen, 2012). In addition, other
children are in family, friends and neighbor care that
is not reported as child care. Child care fatalities are
often private tragedies, characterized by insufficient
investigative measures and a lack of information
sharing between child care programs, parents,
medical examiners, police, and local, state and
national agencies. Many parents of deceased
children receive little or inaccurate information
regarding the circumstances or cause of their child’s
death. In addition, parents find out that providers
have no liability insurance only when a death or
serious injury occurs.
Approximately two-thirds of infants in our country are
in child care, and more than 30 percent of those
children are in child care full time (American Academy
of Pediatrics, 2004). These numbers indicate that less
than 9 percent of SIDS deaths should occur in child
care settings; however that number is closer to 20
If there is a lack of concern by the community at large percent. As national numbers of SIDS deaths
and the early childhood community about deaths in
decreased after the introduction of the “Back to
child care it could be attributed to the low social
Sleep” campaign, SIDS cases in child care did not
visibility of child care-related fatalities, which are often decrease, prompting great concern about the safety
kept quiet. In fact, sleep-related deaths often seem to of sleep practices in child care settings. This issue
be perceived as expected or unavoidable. Numerous continues to be a great concern and potential failing
infant deaths are attributed to SIDS every year; in
of the child care community. The Healthy Child Care
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America Back to Sleep Campaign started in 2003,
designed to protect the safety of infants in child care
by encouraging providers to follow national child care
recommendations and SIDS risk-reduction practices
(Healthy Child Care America, n.d.). In 2005, the
American Academy of Pediatrics completed a study
of state child care regulations related to sleep
environments, including SIDS risk-reduction training
for providers, infant sleep positioning, crib and
bedding safety, and other factors. The study found
that few state regulations mandate back sleeping for
infants and the avoidance of soft bedding, and even
fewer states require SIDS prevention training for child
care providers (Moon, R., et al, 2006).
in SIDS cases (National Conference of State
Legislatures, 2010). Another issue complicating the
prevention, study and death data gathering of SIDS is
that SIDS terminology is not uniform or consistent
across state lines, or even public service
departments, which can lead to the inaccurate
classification or diagnosis of infant deaths (National
SUID/SIDS Resource Center, n.d). In short, there are
few state child care licensing laws and no federal
regulations for SIDS, in general, or as relates to
children in child care settings—no legislation which
requires child care providers to learn about SIDS risk
factors and how to reduce the risk of SIDS. Sleeping
infants continue to die in child care.
As part of its biannual reviews of state child care
licensing regulations, Child Care Aware® of America
(formerly NACCRRA) determines how many states
require family child care providers and center
caregivers to follow SIDS-prevention measures such
as completing training and placing infants on their
backs to sleep. In its 2012 report on family child care
licensing regulations, NACCRRA reported that six
states do not require family child care providers to
adhere to SIDS prevention measures (Leaving
Children to Chance, 2012). The report also found that
10 states do not require providers in small family
child care homes (where six or fewer children are
cared for) to complete any initial health and safety
training (LLC, 2012). Additionally, there are eight
states which do not license family child care homes
that care for fewer than seven children. In its 2011
report on child care center licensing regulations, We
Can Do Better, NACCRRA reported that nine states
do not require center caregivers to place infants on
their backs to sleep (WCDB, 2011).
Failure to Study
The most recent study of child fatalities in child care
is almost 10 years old. Fatalities and the Organization
of Child Care in the United States, 1985-2003
(Wrigley & Dreby, 2005) reports on child deaths
caused by violence/homicide, unintentional injuries,
drowning, motor vehicle crashes and other causes in
child care settings. Because there was no national
reporting tool or federal reporting regulations for child
fatalities in child care (these still do not exist in the
United States), the authors utilized various methods
to gather information, such as newspaper reports,
police reports, court records and data from the few
states that reported deaths in child care. From 1985–
2003 the study found 1,362 child fatalities; 1,030 of
these occurred in “home-based care” (either family
child care or in-home care). The numbers of
deceased children excluded those who died in
irregular care arrangements (where care was not
regularly scheduled with the same provider) (98
deaths) and children whose deaths were attributed to
SIDS (289 deaths). The information and child fatality
numbers in the report only include the deaths the
authors were able to uncover. The number of
unreported or undisclosed child fatalities in child care
continues to be unknown for that time period and
today.
Although federal legislation through CCDBG requires
states to ensure children whose care is subsidized
with federal tax dollars are in programs following
health and safety measures, the U.S. Department of
Health and Human Services is not authorized to
require states to mandate SIDS-prevention
measures.
Fatalities and the Organization of Child Care in the
United States came to several conclusions: 1) In child
care settings, infants are especially vulnerable to
neglect, abuse and death; 2) Child safety in family
child care homes could be improved by requiring
licensing for more family child care programs; 3)
There is a national need for increased training and
Not all states have laws related to SIDS. Among
states with laws related to SIDS, the legislation varies
widely and is often reactive versus preventative; for
example: laws requiring SIDS-related training for
EMS or fire personnel, and laws related to the role of
the medical examiner and the necessity of an autopsy
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professional support for family child care providers.
These conclusions and the need for federal reporting
regulations still ring true today. Up-to-date research
and an updated study of child fatalities in child care is
necessary to inform the development of national
policy regarding child death data gathering and death
prevention in all types of child care in all states.
national agencies, legislators, and child care
professionals from completely understanding the
hazards, errors in judgement, accidents,
circumstances and nature of the acts which fatally
affect children in child care.
For most states, there are no accurate numbers of
child deaths in child care. Even if a state requires
licensed care to report child deaths,
unlicensed/unregulated child care providers and
programs (license-exempt and those operating
illegally) are not required to report child deaths, and
evidence suggests this is where the majority of child
fatalities actually occur (Cambria, 2012). There is
really no national total to tell us how many children
have died in child care in the past year, or five years,
or 10 years, in the United States.
Lack of Reporting Requirements
A major issue inherent in Fatalities and the
Organization of Child Care in the United States
involved the lack of reporting requirements for child
fatalities in child care. This continues to be an issue
today—in 2012 the United States still does not have
federal reporting requirements for child fatalities in
child care. State reporting requirements vary widely.
Child care licensing agencies in only 38 states require
child fatalities in licensed child care settings be
reported to the licensing agency (state licensing
regulations posted on the National Resource Center
for Health and Safety in Child Care and Early
Education in 2012). Twelve states do not require
reporting of children’s deaths in child care centers
and 11 states do not require the reporting of
children’s deaths in family child care homes.
General Child Fatality Information
Several organizations currently collect child fatality
information, for example, the National Center for the
Review and Prevention of Child Deaths. Participation
in this Web-based reporting system is voluntary and
dependent on state practices. Local and state child
death review teams in 40 states currently participate
in this reporting system, which contains data about
the circumstances of the deaths of more than
100,000 children. The system gathers data on most
types of child deaths (violent, accidental, illness),
although not every state reviews deaths from natural
causes (National Center for the Review and
Prevention of Child Deaths, email correspondence).
Among states that do require reporting, the
information gathered varies greatly. Some states do
not have a formal reporting process or even a form
that must be completed as part of the report. How the
information is used varies as well. As children
continue to die in child care, it seems that child death
reports are not used as they might be: to influence
child care provider training requirements, to
encourage federal regulations for reporting child
fatalities in child care, to increase children’s safety
and prevent deaths in child care nationwide.
Another reporting system, the National Violent Death
Reporting System, operates in fewer than 20 states
and includes child maltreatment fatalities, but does
not specify child deaths occurring in child care
programs (Centers for Disease Control and
Prevention (CDC), 2011). The National Center for
Child Care Data and Technology assists Child Care
and Development Fund grantees in collecting and
reporting administrative data, but does not include
reporting related to deaths in child care (Child Care
Technical Assistance Network, 2011).
States that do not require reporting of child fatalities
in child care may fail to collect and maintain critical
information related to children’s health, safety and
survival in child care centers, family child care homes
and in-home care. Without required reporting, states
lack even the most basic information about children’s
deaths in child care settings; in fact, licensing and
other agencies such as Child Protective Services
(CPS) may be unaware that a death occurred in a
child care setting. The lack of comprehensive,
organized information (among states that both do and
do not require reporting) prevents local, state and
The CDC SUID Case Registry Pilot Program
operates in seven states, working to monitor trends in
SIDS and other SUID by collecting comprehensive
data, including contributing and/or causal factors such
as the sleep environment, as well as the quality or
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existence of the death scene investigation. As death
certificates contain limited data and do not describe
the circumstances of death, the CDC SUID Case
Registry uses various information sources including
law enforcement reports, witness interviews, scene
photos, EMS reports and other sources to gather
information. The necessity of these methods
provides yet another example of the challenge of
complete and accurate child death data gathering
(HSRA, 2011).
and NCANDS child deaths in child care do not
include fatalities considered unrelated to abuse or
neglect.
In addition, it is important to keep in mind that each
state defines child abuse and neglect differently,
which means the threshold to substantiate a case of
child abuse and neglect among the states varies
greatly. For example, in the February 2012 case of
the drowning of toddler Juan Cardenas in a baptismal
pool at an unlicensed child care ministry in Indiana,
the Marion County prosecutor’s office declined to file
charges. Under the state’s neglect statute, the state
would have to show the toddler’s death had occurred
as a result of a “knowing act,” but no evidence of
criminal conduct was found and therefore no charges
were filed (Longnecker, 2012). It is unlikely this case
will be reported as a child abuse and neglect fatality.
The National Child Abuse and Neglect Data System
(NCANDS) is comprised of voluntary state reports to
the U.S. Department of Health and Human Services
(HHS). Child fatality information collected by
NCANDS depends on each state’s reporting
requirements, and many states do not require
fatalities in child care to be reported to the state
licensing or child care governance agency. In 2011
the Department published Child Maltreatment 2010
based on reports received by NCANDS. In listing
child fatalities and perpetrators, Child Maltreatment
2010 attributes 12 deaths to “child daycare provider,”
but does not contain specific information about those
deaths (U.S. Department of Health & Human
Services; Administration for Children and Families;
Administration on Children, Youth and Families;
Children’s Bureau). In addition, it does not report
how many of the deaths while with friends, neighbors
or relatives were actually child care situations.
In 2011, the U.S. Government Accountability Office
(GAO) published Child Maltreatment: Strengthening
National Data on Child Fatalities Could Aid in
Prevention in an attempt to ascertain whether or not
NCANDS collects accurate numbers of child fatalities
from maltreatment. GAO examined the Department of
Health and Human Services’ child fatality from
maltreatment reports to determine how
comprehensive the information was, also taking into
consideration the challenges states face in collecting
and reporting information. GAO determined that child
fatalities from maltreatment were most likely
underestimated, and that numerous inconsistencies
existed. In addition, GAO reported that many states
only report child abuse fatalities of children who had
already been in contact with the child welfare system
in the state. In short, the definitions used for child
abuse and neglect vary greatly among the states, as
do state investigative and reporting practices.
When considering issues of reporting neglect, abuse
and fatalities in child care, a relevant question might
be: Can the death of an infant due to unsafe sleep
practices, such as placing an infant face-down on a
soft bed, be equated with neglect or abuse? If so,
how would this affect the NCANDS fatality numbers
for infants and children under age 4? The 2010 report
states that almost 80 percent of the children who died
from abuse or neglect were younger than 4 years old,
with children birth to age 1 making up almost 50
percent of those numbers. Through vigilant
investigation and reporting, if deaths in child care
caused by suffocation due to unsafe sleep practices
or Shaken Baby Syndrome were added, would state
and national agencies take more effective action to
protect children’s safety, rights and lives in child care,
especially that of babies? It is important to remember
that NCANDS child fatality numbers may not include
numerous children who died of neglect or abuse in
child care due to national reporting inconsistencies,
Opportunities for Reporting Requirements
Several federal agencies and programs possess the
potential, through effective communication,
coordination and support strategies, to develop and
require standardized reporting procedures for child
fatalities in all types of child care programs. Only
through national policy and regulations will the United
States be able to collect, track and analyze child
death data in child care settings in a manner that is
accurate, consistent, comprehensive and respectful
of the children who die in child care every year.
5
It is important to collect death data on children in child
care so that policymakers and state licensing and
child care administrators can detect any possible
patterns among the deaths. They can then identify
potential ways to ensure children are safe in child
care, such as strengthening training requirements for
child care providers or licensing requirements related
to allowable group sizes, the ages of children in care,
as well as any applicable requirements for
supervision. More frequent inspections could also be
warranted, which could serve to detect and prevent
any unsafe practices.
CAPTA and CCDBG statutes present opportunities to
authorize, develop and implement reporting
requirements for fatalities in child care. It is instructive
to review deaths in child care settings to detect
patterns and potentially put in place policies to
promote better safety (e.g., training in safe sleep
practices, more effective supervision policies, etc.).
There are 1.6 million children whose care is paid for
by federal funds through CCDBG (Office of Child
Care, 2012). While we know the types of settings
these children are in (centers, family child care
homes, licensed, or unlicensed care), there is no
requirement under current law to report child deaths
or serious injuries in settings paid for through federal
funds.
The Child Care and Development Block Grant
(CCDBG) is a prime example of a federal program
with the potential to require all 50 states and the
District of Columbia to collect data and report deaths
in child care. Complete and accurate data gathering
and reporting regarding child fatalities in all types of
child care could be required for states to receive
CCDBG grant funding and support. Currently CCDBG
does not require state grantees to report child
fatalities or near deaths in child care programs (HHS,
2012). CCDBG also does not require inspections.
There are another 803,000 children whose care is
paid for through the Temporary Assistance for Needy
Families (TANF) program (Child Care Bureau, 2007).
Other than the aggregate amount of funds spent on
child care and the number of children whose care is
paid for through TANF, there are no other reporting
requirements (not even the minimal reporting of
settings or licensing status). For all children in child
care, it is important to better understand what is
needed to keep them safe and healthy. But, for those
children whose care is paid for with federal funds,
there should be accountability for the expenditure of
those funds and the safety of children.
The Child Abuse Prevention and Treatment Act
(CAPTA) requires suspected child abuse and neglect
to be reported; however the Act does not differentiate
deaths that occur in child care settings from those
occurring in other settings. CAPTA does not collect
information related to child deaths by causes other
than abuse or neglect, for example, drowning,
accidents, unintentional injuries, SIDS and other
causes of death that may occur in child care settings.
Therefore, CAPTA child death numbers, for example
1,770 children in 2009, do not include SIDS deaths
that may be attributed to neglectful sleep practices
(U.S. Department of Health and Human Services, et
al, 2011). Due to investigative and reporting
inconsistencies at local and state levels, CAPTA data
may or may not include deaths caused by Shaken
Baby Syndrome in child care settings. Although
CAPTA state funding requires the public disclosure of
any child abuse and neglect fatalities and near
fatalities, the recent report State Secrecy and Child
Deaths in the U.S. found that not all states fully
comply with this requirement; deaths that are not
disclosed almost certainly involve child fatalities in
child care settings (Children’s Advocacy Institute,
2012).
Another way to ensure that children are safe in child
care is to require a comprehensive background check
for child care providers before allowing them to work
in child care centers or become licensed to care for
children in their home. A comprehensive background
check includes a fingerprint check against state and
federal records, as well as a check of the sex
offender registry and child abuse registry. Yet today,
only 10 states require a comprehensive check (a
check requiring all four of those elements) of those
who work in child care centers and only nine states
require a comprehensive check for those licensed to
care for children in their homes (Child Care Aware®
of America 2011; Child Care Aware® of America
2012).
CCDBG requires a state plan for all licensed child
care to be submitted to HHS every two years. The
Act also requires funds be used to promote “the
health and safety of children.” Currently about 89
percent of CCDBG funding is used to pay for the care
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of low-income children (Office of Child Care, 2012).
Yet, the Act does not require funds to be used in
licensed settings and does not require a background
check for providers caring for children whose families
receive a federal or state subsidy. CCDBG offers a
valuable opportunity to require comprehensive
background checks for child care providers—a critical
step toward preventing abusive deaths in child care.
Fingerprinting and cross-checking child care
providers against national and state databases for
criminal records and child abuse history are crucial to
protect our children. In states that do not use a
fingerprint check against both state and federal
records, individuals can circumvent the background
check process by using an alias.
parents (including more disclosure about the
background of providers and posting inspection
reports online to ensure parents have full information
in choosing among providers), conducting regular
inspections, requiring and analyzing standardized
child death reporting—these are all effective and
necessary strategies to protect our children and
prevent deaths in child care settings.
Lack of State Reports on Deaths in Child Care
The major reason for the lack of accurate information
on the number of fatalities in child care is that there
are no organized local, state and national procedures
for reporting the death of a child in a child care
setting. Many states lack any regulations or
requirements for reporting the death of a child in child
care. Some states do not have a formalized process
for reporting or recording deaths. Some states do not
require that deaths occurring in child care be
identified separately from general child fatality
statistics.
In many states, a criminal history and/or conviction
does not disqualify an individual from becoming
licensed to provide child care, even if a person has
been convicted of a violent crime such as battery or
child abuse (Hansen, 2012). Thirteen states do not
check the child abuse registry before granting a
license to those who apply to operate a family child
care home (Child Care Aware® of America, 2012).
Seven states do not check the child abuse registry to
see if those who apply to work in a child care center
are on a state child abuse and neglect registry (Child
Care Aware® of America, 2011). If states choose to
license individuals with a history of crime or violence,
they should at least disclose that information to
parents by making the criminal records public
knowledge (versus the records being kept confidential
by states). Disclosing this information to parents and
the public at large is essential to ensure that parents,
as consumers, can make informed choices among
providers. Parents assume a background check
means that providers are safe. In the case of families
where the care of children is paid for with a federal
subsidy, there should be a comprehensive check to
ensure that children are safe and federal or state
funds are being expended in an accountable manner.
For the purposes of this article, several states were
contacted regarding the reporting of child deaths in
child care. The results of these calls suggest: 1)
States handle the reporting of child fatalities in child
care programs according to their own voluntary or
required regulations; 2) In some states there is
confusion as to what, if any, office is responsible for
this information; 3) Child fatalities in child care
programs may or may not be included in reported
child abuse and neglect deaths; 4) Most states do not
require the reporting and tracking of child deaths in
child care.
A few examples of state inconsistencies are as
follows: The Minnesota Child Mortality Review,
working with the National Center for the Review and
Prevention of Child Deaths, collects data on child
deaths that occur in licensed care, but does not
identify these separately from general child death
information (Minnesota Department of Human
Services, 2011). In Minnesota, 82 of the 85 deaths in
licensed child care since 2002 have happened in
family child care homes -- most of those who died
were infants. In Minnesota this year alone, there have
already been seven deaths in licensed programs
(Schrade, Olson, Howatt, 2012).
Working together, leaders, legislators, parents and
child care providers must take the necessary steps to
protect children of all ages in all types of child care.
Taking action to prevent abuse and fatalities,
enacting careful background checks, requiring
licensing for providers caring for unrelated children
and children whose care is paid for by federal funds,
providing education and support for providers
including training, providing consumer education to
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Montana requires licensed child care centers and
family child care programs to report the death of a
child to the state child care licensing agency. In 2002,
the Children’s National Medical Center determined
that 20 percent of infant deaths attributed to SIDS in
Montana occurred in child care settings, with
increased numbers in family child care (Montana
State Fetal, Infant and Child Mortality Review Team,
2002). Montana is where 1-year-old Dane died when
his licensed child care provider gave him a lethal
dose of cold and allergy medicine in an attempt to
make him fall asleep (other children in the program
tested positive for the medication as well) (Tuttle,
2011).
state and national agencies. Most importantly, it will
save children’s lives.
The Need for State and National Reporting
Requirements
A national policy on child deaths in child care,
including regulations for standardized reporting, is
needed:
 To create an organized, systematic,
standardized reporting procedure that
provides an accurate count of the number of
child fatalities occurring in child care
 To better understand the reasons and causes
for child fatalities in child care
From 2004 to 2007, 49 children died in unregulated
 To increase public awareness and
care in Texas; this number only includes known
understanding of risks and actions that lead
deaths (Sebesta, 2009). Florida, where 2-year-old
to child fatalities in child care
Haile was left in a hot van for six hours, does not
 To improve communication and information
require deaths in child care be reported (Whigham &
sharing among parents, child care providers
Kleinberg, n.d.). Virginia requires deaths in licensed
and public service professionals
care be reported; however, 3-month-old Teagan was
 To ensure parents are educated consumers
found unresponsive in an unlicensed child care where
in selecting child care
23 children age 4 and under were cared for by only
 To enable policymakers to review, analyze
two adults (Olabanji, 2012). Kentucky, where 2-yearand utilize detailed child fatality information in
old Ja’Cory died after choking on a push pin, does not
order to:
require deaths in child care family homes to be
o Identify significant and common risk
reported (Cook, 2011). Massachusetts requires
factors
deaths be reported, such as the death of 17-montho Identify patterns and trends in child
old Gabriel, who was found dead in a sweltering van
deaths in child care
outside a basement child care he didn’t attend—a
o Understand training and support
program that shouldn’t have been operating because
needs for child care providers in
it lacked fire extinguishers, evacuation plans and the
centers and family child care
necessary city inspection (Moskowitz, Cramer &
programs
Guilfoil, 2011).
o Increase delivery of needed training,
supports and services to child care
These tragedies demonstrate the urgent need for
providers, children and parents
national policy regarding the reporting of child
o Identify and recommend necessary
fatalities in all types of child care, including
changes in policy, procedures and
unlicensed child care. The evidence also reinforces
child care regulations
that all states need to strengthen licensing
o Protect children’s lives and prevent
requirements, increase the availability of licensed
future deaths
care, strengthen basic training requirements (such as
safe sleep practices and other training that promotes Call for Awareness and Action
child safety), and review state sanction policies when
unsafe practices are found. Federal reporting
Increased awareness among parents, child care
requirements for child fatalities in child care will help
providers, public service agencies and the early
identify significant risk factors and patterns in child
childhood community is essential to protecting
deaths, as well as the need for changes in legislation, children’s health, safety and survival in child care.
licensing requirements, child care provider training,
With accurate child death data gathering and effective
and communication and coordination between local,
communication strategies, parents, policymakers and
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
state child care administrators can gain the
information they need to make informed decisions
about issues such as selecting child care, formulating
child care policy, satisfying training needs and
requirements, decreasing child death risk factors and
utilizing detailed information to prevent deaths and
near-fatal injuries.

Child Care Aware® of America recommends:








States receiving federal funds for child care
or child abuse prevention and reporting be
required by law to report all child fatalities
and near-fatality incidents occurring in
licensed/regulated child care using a
standardized, Web-based reporting system
Federal funds be used to provide the
supports needed by states to utilize the
reporting system
States implement regulations requiring that
child fatalities in all types of child care be
reported within 48 hours to the state child
care licensing agency
The National Center for the Review and
Prevention of Child Deaths program and
reporting form be used as a model for
reporting child fatalities specific to child care
Specific procedures for child care providers,
licensing agencies and public service
professionals (police, medical examiners,
child protection officers, social services) be
established and followed when handling and
reporting a child fatality in a child care setting
Comprehensive background checks
(including the use of fingerprints) be required
for child care providers in licensed/regulated
child care programs as well as licenseexempt providers caring for children whose
care is paid for with federal or state funding
(a contract, certificate, or voucher)
Licensing exemptions for child care programs
and providers be eliminated and states be
required to inform parents when their child is
in a license-exempt program if state or
federal funds are being used to subsidize the
care
States increase their efforts to communicate
the dangers of choosing unlicensed care to
parents




Health and safety training for licensed,
license-exempt and unlicensed child care
providers on topics such as SIDS-prevention
and safe sleep practices, Shaken Baby
Syndrome, Handling Stress, Positive
Guidance and Family Involvement be
increased and strengthened
All child care programs be inspected prior to
being licensed/regulated and all programs in
which federal funds are being used to
subsidize child care be inspected before
providing care
All licensed/regulated child care programs
and programs in which the care is being
subsidized with federal funds be monitored at
least twice a year
Licensed/regulated providers be required to
have liability insurance, or at a minimum,
require disclosure to parents as to whether or
not the provider has liability insurance
The confidentiality of child and family
personal information in child death reporting
be maintained, as desired by the family
Professionals in early care and education
advocate for improvements in the training
and monitoring of child caregivers to ensure
that children do not die in child care and early
learning settings
Working together, the early childhood professional
community, parents, licensing agencies, public
service professionals and legislators can create and
maintain a national system for reporting child fatalities
in all types of child care. Protecting the safety and
survival of millions of children in child care should be
a national priority shared by all. Advocating for child
death reporting in child care protects our children, our
families and our future. Somewhere in the United
States today, it’s very likely a child died in child care.
Why aren’t we outraged?
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Note: This article was prepared by Vanessa DiLeo and Sherry Patterson for Child Care Aware® of America.
For additional information, please contact Grace Reef, Chief of Policy & Evaluation, Child Care Aware® of
America at [email protected] . Child Care Aware® of America, formerly the National Association of
Child Care Resource and Referral Agencies (NACCRRA), is our nation’s leading voice for child care. We work
with more than 600 state and local Child Care Resource and Referral agencies to ensure that families in
every community have access to quality, affordable child care. To achieve our mission, we lead projects that
increase the quality and availability of child care, offer comprehensive training to child care professionals,
undertake nationally recognized research and advocate for child care policies that positively impact the lives
of children and families. To learn more about Child Care Aware® of America and how you can join us in
ensuring access to quality child care for all families, visit us at www.naccrra.org.
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