1. Moon RY, Hauck FR, Colson ER. Safe infant sleep interventions: what is the evidence for successful behavior change? Curr Pediatr Rev. 2016;12:67-75.
  2. Moon RY, Byard RW. Need for a working classification system for sudden and unexpected infant deaths. Pediatrics. 2014;134:e240-e241.
  3. Sauber-Schatz EK, Sappenfield WM, Shapiro-Mendoza CK. Comprehensive review of sleep-related sudden unexpected infant deaths and their investigations: Florida 2008. Matern Child Health J. 2015;19:381-390.
  4. Horne RS, Hauck FR, Moon RY. Sudden infant death syndrome and advice for safe sleeping. BMJ. 2015;350:h1989.
  5. Hunt CE, Darnall RA, McEntire BL, Hyma BA. Assigning cause for sudden unexpected infant death. Forensic Sci Med Pathol. 2015;11:283-288.
  6. Filiano JJ, Kiney HC. A perspective on the neuropathologic findings in victims of the sudden infant death syndrome: the triple risk model. Biol Neonate. 1994;65:194-197.
  7. Goldstein RD, Trachtenberg FL, Sens MA, Harty BJ, Kinney HC. Overall postneonatal mortality and rates of SIDS. Pediatrics. 2016;137:e20152298.
  8. Hunt CE. Sudden infant death syndrome and other causes of infant mortality: diagnosis, mechanisms, and risk for recurrence in siblings. Am J Respir Crit Care Med. 2001;164:346-357.
  9. American Academy of Pediatrics. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128:e1341-e1367.
  10. Centers for Disease Control and Prevention (CDC). Suffocation deaths associated with use of infant sleep positioners—United States, 1997-2011. MMWR Morb Mortal Wkly Rep. 2012;61:933-937.
  11. Ajao TI, Oden RP, Joyner BL, Moon RY. Decisions of black parents about infant bedding and sleep surfaces: a qualitative study. Pediatrics. 2011;128:494-502.
  12. Joyner BL, Gill-Bailey C, Moon RY. Infant sleep environments depicted in magazines targeted to women of childbearing age. Pediatrics. 2009;124:e416-e422.
  13. Shapiro-Mendoza CK, Colson ER, Willinger M, Rybin DV, Camperlengo L, Corwin MJ. Trends in infant bedding use: National Infant Sleep Position study, 1993-2010. Pediatrics. 2015;135:10-17.
  14. Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ; National Infant Sleep Position study. Trends in infant bed sharing in the United States, 1993-2000: the National Infant Sleep Position study. Arch Pediatr Adolesc Med. 2003;157:43-49.
  15. Li L, Zhang Y, Zielke RH, Ping Y, Fowler DR. Observations on increased accidental asphyxia deaths in infancy while cosleeping in the state of Maryland. Am J Forensic Med Pathol. 2009;30:318-321.
  16. Hauck FR, Tanabe KO, McMurry T, Moon RY. Evaluation of bedtime basics for babies: a national crib distribution program to reduce the risk of sleep-related sudden infant deaths. J Community Health. 2015;40:457-463.
  17. Rechtman LR, Colvin JD, Blair PS, Moon RY. Sofas and infant mortality. Pediatrics. 2014;134:e1293-e1300.
  18. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005;116:e716-e723.
  19. Guntheroth WG, Spiers PS. Thermal stress in sudden infant death: is there an ambiguity with the rebreathing hypothesis? Pediatrics. 2001;107:693-698.
  20. Auger N, Fraser WD, Smargiassi A, Kosatsky T. Ambient heat and sudden Infant death: a case-crossover study spanning 30 years in Montreal, Canada. Environ Health Perspect. 2015;123:712-716.
  21. Varghese S, Gasalberti D, Ahern K, Chang JC. An analysis of attitude toward infant sleep safety and SIDS risk reduction behavior among caregivers of newborns and infants. J Perinatol. 2015;35:970-973.
  22. Patton C, Stiltner D, Wright KB, Kautz DD. Do nurses provide a safe sleep environment for infants in the hospital setting? An integrative review. Adv Neonatal Care. 2015;15:8-22.
  23. Grazel R, Phalen AG, Polomano RC. Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: an evaluation of nursing knowledge and practice. Adv Neonatal Care. 2010;10:332-342.
  24. McMullen SL, Fioravanti ID, Brown K, Carey MG. Safe sleep for hospitalized infants. MCN Am J Matern Child Nurs. 2016;41:43-50.
  25. Hauck FR, Tanabe KO. International trends in sudden infant death syndrome: stabilization of rates requires further action. Pediatrics. 2008;122:660-666.

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Laura A. Stokowski, RN, MS
Clinical Editor


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Teaching Safe Sleep: Are You Giving the Best Advice?

Laura A. Stokowski, RN, MS  |  February 17, 2016

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Slide 1

Advising Parents: Prevention of Sleep-Related Death in Infancy

Current best practices for teaching parents strategies to reduce the risk for sleep-related infant death are based on the American Academy of Pediatrics' 2011 expanded recommendations about a safe sleeping environment for infants in the United States. However, typical infant and family sleep environments and infant caretaking rituals vary considerably by country and culture. Differences may include, but are not limited to, bedsharing practices, use of pacifiers (dummies), and types of beds, bedding, sleeping clothing, and swaddling materials. Healthcare professionals should examine research conducted in the specific populations that they serve, as well as recommendations based on that evidence, in determining the appropriate guidance to offer outside of the United States.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 2

Sleep-Related Death in Infancy

It's a tragic fact that more than 4000 sleep-related sudden infant deaths occur annually in the United States.[1] The terminology for unexpected death in infancy, with its changing and overlapping definitions, can be confusing to everyone—from clinicians to parents and those who must determine the cause of an unexpected infant death.[2] Many deaths that might have been attributed to sudden infant death syndrome (SIDS) in years past are now being classified as other types of sleep-related death. Sleep-related sudden unexpected infant deaths (SUIDs) encompass accidental deaths from suffocation, asphyxia, and strangulation, as well as presumed deaths from SIDS. For the purposes of prevention and patient education, however, one common denominator is the sleep environment. In a Florida study, 80% of sleep-related SUIDs were reported among infants placed in unsafe sleeping environments.[3]

Image from iStock

Slide 3


SIDS is the leading cause of death among infants aged 1 month to 1 year.[4] When an infant's death cannot be explained after a thorough case investigation (a forensic death scene investigation, autopsy, and review of the clinical history), SIDS is assigned as the cause.[5] The "triple hit theory" is that SIDS occurs in (1) an intrinsically vulnerable infant (2) during a critical period of development (age < 6 months is the period of greatest risk) who is (3) exposed to an exogenous stressor, such as prone position, overbundling, or airway obstruction.[6]

We have no biomarkers for SIDS, so risk reduction must take into account the known factors that increase the risk for death,[7] especially in an unsafe sleep environment. Although commonly considered a risk factor, whether the risk for SIDS is truly increased in siblings of infants who died of SIDS is controversial.[8]

Image from iStock

Slide 4

Protection From SIDS

One of the strongest protective factors against SIDS is breastfeeding. Many studies show that breastfeeding, of any extent or duration, is associated with a reduced risk for SIDS, ranging from 45% for partial or short-term breastfeeding to 73% for exclusive breastfeeding.[9] Whether breastfeeding can counteract other modifiable or nonmodifiable risk factors for SIDS (such as smoking) is not known. Parents should avoid smoking (both prenatally and postnatally), and drug and alcohol use (especially combined with infant co-sleeping).

Keeping infant and family member vaccinations up to date and avoiding exposing the infant to sick persons are additional protective measures.

Image from iStock

Slide 5

Safe to Sleep (Formerly Back to Sleep)

"Back to sleep" transitioned to "safe to sleep" when it was recognized that every facet of the sleep environment—from sleep position to bedding, clothing, and temperature of the surrounding air—was important in protecting the sleeping infant.

Safe-to-sleep principles must be used for every sleep (including naps) and in every setting, including daycare or a babysitter's home. Parents need to be confident in telling nannies, babysitters, grandparents, and other friends and relatives who care for the infant to adhere strictly to their instructions about the sleep environment.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 6

Sleep Position

Supine sleeping was the first major change in the campaign to prevent SIDS, and it continues to be the cornerstone of safe sleep. Supine sleep should begin at birth and continued until the infant can roll from supine to prone and from prone to supine. At that time, the infant can be allowed to remain in the sleep position that he or she assumes.[9]

Prone sleeping is a major risk factor for SIDS,[4] although side sleeping also raises the risk, especially in infants unaccustomed to sleeping prone. Many infants who died were found prone after being placed on their sides to sleep with positioning devices.[10] Thus, parents should be instructed to exclusively use the supine position for sleep, and never to use sleep positioners, wedges, or rolled blankets to maintain a side-lying sleep position.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 7

The "Risk of Choking" Myth

Because infants are typically put down to sleep right after eating, some parents and many healthcare professionals are concerned about a risk that infants will choke on or aspirate stomach contents in the supine position. However, healthy infants placed supine for sleep are less likely to choke than prone sleeping infants,[4] because in the supine position, the upper airway is above the esophagus, allowing any regurgitated milk to be readily swallowed. In the prone position, the esophagus is above the upper airway, making aspiration more likely.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 8

The Safe Crib

The safest crib contains nothing but a baby, sleeping supine on a firm mattress and tightly fitted crib sheet. It does not contain bumper pads, quilts, blankets, pillows, soft toys, positioning devices, or reachable toys with strings. The crib's slats and construction conform to safety standards set by the Consumer Product Safety Commission (visit their Safe to Sleep Crib Information Center). The latest crib standards eliminate the drop-down sides that were associated with many infant injuries and deaths from entrapment, so parents using a pre-2011 crib should be advised that these cribs are not safe.

An emphasis is often placed on avoidance of soft bedding that might cover an infant's face, but it is equally important to advise parents not to place soft bedding underneath a sleeping infant—a common practice to increase the perceived comfort of the infant's sleep surface.[11]

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 9

The Unsafe Crib

It can be difficult to counter the media and advertisements that target pregnant women. A recent study found that two thirds of parenting magazine images showed unsafe sleeping environments, and that such images suggest to parents that these practices are normal and even desirable.[12] Although the use of potentially hazardous bedding has declined in recent years, it is still highly prevalent among younger, nonwhite, and non–college-educated mothers.[13] Recognition of the dangers of soft bedding on top of sleeping infants does not prevent the use of soft bedding underneath sleeping infants.[13]

As manufacturers began realizing that some parents were no longer purchasing traditional bumper pads, they began selling what they claimed were "breathable mesh crib liners," to "keep the baby's limbs inside the crib" and "prevent suffocation." Parents should be advised that these crib liners are unnecessary, potentially dangerous, and have no role in "reducing suffocation."

Image courtesy of Stephanie Cajigal/Medscape

Slide 10


Contrary to the teachings of much of the past century (and to the dismay of many grandparents), research now shows that sleeping in the parents' bedroom is safest for infants throughout the first 6-12 months of life. The ability to monitor the baby more closely may lower the risk for sleep-related death and may prevent such events as suffocation, strangulation, or entrapment.[4]

Keeping the crib in the mother's room also allows closer proximity for feeding, regardless of feeding method. Breastfeeding mothers should be aware that the safest strategy during the night is to place the infant back in his or her crib after feeding, rather than falling asleep while breastfeeding or placing the infant down to sleep in the parents' bed.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 11

No Bed-Sharing

More than one half of all recent sudden and unexpected deaths in infants occurred in a bed-sharing situation, meaning an adult or child sleeping on the same surface with the baby.[4] Bed-sharing is extremely common—at least 45% of US parents admit to this practice,[14] and it is even more culturally entrenched in other parts of the world. Despite being common, co-sleeping has been a factor in a high proportion of sudden infant deaths. In a 1-year review of 102 infant deaths in Maryland, 46 infants (45%) were found co-sleeping.[15] Bed-sharing is not recommended in the United States, and parents are particularly cautioned to avoid bed-sharing if they smoke, drink, or use drugs (even some prescription drugs).

The decision to bed-share can be cultural or personal, and sometimes economic. The question "Do you have a crib for the baby?" is easily neglected.[16] Free crib programs exist for low-income, high-risk families and should be pursued, but merely acquiring a crib does not guarantee its use. Healthcare professionals should inform all parents of the risks and the latest recommendations about bed-sharing. No study to date has found bed-sharing to have a protective effect on SIDS.[4]

Image courtesy of Stephanie Cajigal/Medscape

Slide 12

Sleep Clothes and Blankets

The ideal way to dress any infant for sleep is in clothing (one-piece sleeper or sleep sack/sleeping bag) of appropriate weight for the season, so that no swaddling or blankets are needed. If blankets are used in the crib, infants should be placed with their feet at the foot of the crib and the blanket (of a thin and lightweight, rather than a fluffy or heavy, construction) should be tucked in on three sides to reduce the risk for the head becoming covered. The top edge of the blanket should not rise above the armpits or reach the baby's face. Placing the infant's feet near the foot end of the bed reduces (but does not eliminate) the chances that the baby will slip down under the blanket. Infant sleeping bags, if used, should be the correct size for the infant, with a fitted neck and armholes or sleeves to keep the baby warm and no hood to avoid any chance of the head becoming covered.[4] Healthcare professionals should be aware that to date, no evidence exists to support the effectiveness of sleeping sacks or sleeping bags in preventing SIDS.[4]

Image courtesy of Stephanie Cajigal/Medscape

Slide 13

Where Not to Sleep

Sleeping on a sofa or in a chair with an infant should always be avoided because of the significantly increased risk for SIDS. Recent data found that 13% of infant sleep-related deaths occurred while co-sleeping on a sofa.[17]

Parents should avoid putting infants down to sleep or leaving sleeping infants in car seats and strollers, swings, baby carriers, or slings. Infants should not be propped in a sitting position for sleep. A newborn's head is relatively heavy and neck muscles are weak, and it is very easy for the head to drop and block the airway. In cloth baby carriers, the baby can slide down and the head can drop so that the face is buried in the fabric. In baby carriers, parents should keep the infant's face visible and above edge of the fabric, and the nose and mouth unobstructed.

Image from iStock

Slide 14

Pacifier for Sleep

Although the mechanism is not understood, routine use of a pacifier for naps and bedtime is protective against SIDS, even if the pacifier falls out of the infant's mouth.[18] In other words, it is not necessary for parents to keep replacing the pacifier during sleep. Pacifiers should not be introduced for the first 3-4 weeks, while breastfeeding is being established, and use of a pacifier should be continued for the first year of life, when the need for sucking is strongest.[18] Because of the risk for strangulation, pacifiers should not be hung around the infant's neck, and pacifiers that attach to infant clothing should not be used with sleeping infants.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 15

Warmer Is Not Better

Many parents have a tendency to overdress their infant, and even to cover their infant's face and head when out of doors. Thermal stress through overdressing or overbundling the infant, or exposing the infant to high ambient temperatures, is associated with higher risk for sudden infant death.[19,20] However, the definition of "overheating" is not standardized. In general, infants should be dressed appropriately for the environment, with no more than one layer more than an adult would wear to be comfortable in that environment. Similarly, the air temperature should be adjusted to be comfortable for an adult.

Parents and caregivers should be taught to evaluate the infant for signs of overheating, such as sweating or the infant's skin (on the chest) feeling hot to the touch. Overbundling and covering of the face and head should be avoided. There is currently insufficient evidence to recommend the use of a fan as a SIDS risk-reduction strategy. If a fan is used to create a little air movement, it should not be directed into the infant's face.

Image from iStock

Slide 16

Tummy for Play

Supervised, awake, daily "tummy time" is thought to be necessary for normal development and strength of the neck muscles and upper body, and to minimize occipital flattening and positional plagiocephaly. The Safe to Sleep program recommends that tummy time should begin as early as possible (ideally, on the first day home from the hospital), using toys or the parent's face to encourage the infant to lift his or her head. Tummy time can take place on the floor or on a supine parent's chest. Parents can attempt two to three tummy sessions each day for a short period (3-5 minutes), extending the duration if the infant seems to enjoy the experience.

Image courtesy of the Safe to Sleep® campaign, for educational purposes only; Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep® is a registered trademark of the US Department of Health and Human Services.

Slide 17

Actions Speak Louder Than Words

Many parents model their infant-caregiving behaviors on what they witness during the birth hospitalization or time spent in a neonatal unit. Several studies have found that a substantial number of nurses and other healthcare professionals disagree with aspects of the American Academy of Pediatrics safe sleep recommendations,[9] and continue to demonstrate and recommend unsafe practices, such as prone or side sleeping.[21-24] Whether the reluctance of some healthcare professionals to endorse safe sleeping guidelines has had any impact on rates of sleep-related death is not known, but with the recent plateauing of SIDS rates after years of improvement, this is an area requiring further attention.[25]

Image from iStock

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