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Deborah Stenseng had an unusual way of comforting infants in her home day care. When they got fussy or wouldn't take a bottle, the Duluth woman opened her shirt and had them suckle on her breast, even though she wasn't lactating or breast-feeding children of her own.

Worse, Stenseng deceived some parents about the practice and defied others who asked her not to do it with their children, regulators later concluded. Eventually, a complaint reached St. Louis County authorities, who shut down Stenseng's day care in January and revoked her license in April. "Serious personal boundaries ... were crossed," licensing officials concluded.

Though extreme, Stenseng's case reflects an inherent problem in licensed family child care -- a problem that may be linked to a recent increase in child care deaths in Minnesota. Operating with minimal training, spotty inspections and inconsistent rule enforcement from one county to another, home-based providers can engage in practices that range from inappropriate to dangerous as they care single-handedly for as many as a dozen children.

Minnesota has some of the leanest training requirements in the nation for in-home child care, according to a Star Tribune review of licensing data. Providers don't need high school diplomas or child development expertise to get licensed. Inspections are required only every two years, and one watchdog group estimates that Minnesota's ratio of inspectors to providers is among the nation's lowest.

The risk is that low standards result in low quality, said Amie Lapp Payne, who wrote an influential 2011 report for the National Association for Regulatory Administration on child-care safety. "If it isn't a regulatory requirement, they aren't going to do it," she said.

Even with lax standards, thousands of Minnesota day-care providers nurture children skillfully, with no deaths or safety violations. But a review of public records shows that the rules allow substandard operators to stay in business and place children at risk.

One former provider in Delano, for example, shoved a child's face into a pool of urine on her floor in early 2010 after discovering that the child had had a toileting accident. Documents show that the woman pressed hard enough to bruise the child's forehead.

Other providers dunked children in water, put hot sauce on their tongues, or grabbed or hit them hard enough to break bones. Altogether, the newspaper found 70 cases of corporal punishment since 2007 -- even though it is forbidden under state law.

In the last decade, the Legislature has considered raising training and safety standards for home child care several times. But lawmakers have repeatedly hedged, out of concern that higher standards would increase costs or represent government intrusion for these small businesses.

Even the Minnesota Licensed Family Child Care Association, which represents small, in-home providers, has encountered resistance when seeking more funding so that providers could be mentored by experienced colleagues.

"[It's] the idea that, 'Why do people who are taking care of little kids need this?' " said Katy Chase, the association's executive director. "There's just a feeling we're born able to properly care for children."

The result is a two-tier child-care system: Roughly 1,500 large child-care centers with more employees, higher training requirements and inspections by Minnesota regulators; and about 11,100 small in-home day cares, where providers often operate in isolation with little support and scrutiny.

'Adults get worn down'

Reviewing licensing documents and death records, the Star Tribune found that 82 of 85 deaths in licensed child care since 2002 have taken place in homes, not centers. The number of deaths has nearly doubled in the past five years.

One of the few researchers to examine the causes of child-care deaths nationally said the absence of oversight increases risks for children.

Julia Wrigley, a sociologist at the City University of New York, found a higher rate of deaths in the nation's licensed home day cares than in centers. She concluded that large child-care centers are safer because they have multiple workers on hand to monitor children and stop co-workers from making mistakes.

"Adults can get worn down. They can get distraught and frustrated and these all can be risk factors when caring for a lot of little kids," she said. "If you have other adults there ... they can ensure that safe standards are maintained."

A Star Tribune review of 1,100 disciplinary actions issued since 2007 against Minnesota licensed day-care homes showed that the isolation of providers can play a significant role. More than 300 sanctions resulted from lapses in child supervision -- often because providers were spread thin.

In Rochester in 2010, a provider confined two preschoolers to a basement for seven hours (keeping one in a 4-foot-square pen) to keep them away from a furnace repair man. At a Rose Creek day care last fall, a 1-year-old was left unattended and wandered two blocks away to a hardware store.

Tighter enforcement?

To aid providers who are struggling with safety and quality, advocates believe Minnesota needs tougher standards and enforcement.

Many child deaths reviewed by the Star Tribune involved providers who didn't follow even basic safe-sleeping rules. At least 10 deaths since 2007 involved infants placed to sleep on their stomachs -- a clear violation of guidelines -- or on unsafe surfaces. Several deaths involved napping infants who weren't checked for long periods of time -- in one case three hours.

The state requires that in-home providers and center workers be within sight or hearing of sleeping infants. But only at child-care centers are workers required, in most cases, to visually check sleeping infants every 15 minutes.

In Kansas, which overhauled its child-care rules in 2010, in-home caregivers must check on sleeping children every 15 minutes. It is one of at least six states that require in-home providers to observe children during their nap times.

In a May 3 letter to family providers, Minnesota Department of Human Services Inspector General Jerry Kerber said his agency would examine the "vast differences" in death figures between centers and licensed homes, and whether additional training or supervision is needed.

In addition, some advocates believe Minnesota needs better day-care inspections. Child Care Aware of America, a research and watchdog group, estimates that Minnesota has one county inspector for every 150 family child care homes -- 10th worst in the nation.

Actual rates vary widely by county. In Anoka County, three inspectors have caseloads of more than 200 providers and aren't able to spend as much time with individual providers as they would like.

"If we're really wanting to know what's going on in a home, the best way ... is to be there in person, eyeball to eyeball," said Evelyn Nelson, who supervises the Anoka office. "We don't have the people power to do that."

In 26 states, inspections occur at least once a year, with 14 states inspecting in-home providers twice a year or more, according to Child Care Aware of America's survey. Four states inspect at least quarterly, including Wyoming, where there is an inspector for every 66 home child care providers.

Better training?

Better training of child care providers also can improve the quality of care, according to several research studies.

Minnesota requires in-home providers to be trained in first aid and CPR before they are licensed, but no training in child development is required until after they open. The state's requirement of eight hours of annual training was 33rd lowest among 42 states that license small child care homes, according to Child Care Aware.

Wisconsin requires at least 40 hours of initial training, including child development, and then 18 hours annually.

"We think [training] increases the likelihood children will be safer in care," said Grace Reef, Child Care Aware's public policy director. "But it's also about healthy [child] development."

Responding to the Star Tribune's ongoing investigation, state regulators recently recommended increased training in safe sleep positioning and CPR.

Yet proposals to increase training can face political resistance. In 2006 Minnesota increased its annual training requirement from six hours to eight after lawmakers opposed increasing the total to 12.

"Conservatives railed against 'the nanny state,' " said John Hottinger, a former DFL state senator who sponsored the training bill.

Some legislators remain skeptical of more regulation. "It never ends. We add regulation on regulation, training on training," said Rep. Steve Gottwalt, R-St. Cloud. "Unless you've got real good evidence that six hours results in 'X' amount of better safety for kids, then why not 12 hours? Why not 36 hours? Why not require day-care providers to have a master's degree?"

Training isn't a cure-all, Wrigley said. Her deaths study concluded that the environment of family child care was more problematic than a lack of education. And Stenseng, the provider who lost her license because she used breast-suckling to control behavior, had college training in psychology and social work.

Stenseng said she created her own licensed child care because she was dissatisfied with options for her children and wanted to create a facility that supported alternatives such as cloth diapers, attachment parenting and extended breast-feeding. She disagreed with the state report, arguing that most parents were aware of her "comfort nursing" practice. "To them," she said, "it was a very natural fit" with their parenting philosophies.

Katy Chase of the Family Child Care Association believes providing more mentors would raise child-care quality. Public funding covers mentoring for only five providers a year, she noted.

Payne, the author of national child-care guidelines, said ultimately it's up to states to ensure safety at home-based day care.

"This is their house," she noted. "But is it safe enough for kids? That's the bottom-line question."