How Should We Implement Safe Sleeping Recommendations in the NICU Setting?

Catherine L. Witt, RNC, MS, NNP


May 26, 2006


In the NICU, how can we implement the American Academy of Pediatrics' recommendations for safe sleep and educate parents?

Response from The Expert Catherine L. Witt, RNC, MS, NNP

The American Academy of Pediatrics recommends several safe sleeping practices for infants in order to decrease the incidence of sudden infant death syndrome (SIDS). These include placing infants on their backs to sleep; using safety-approved cribs and firm mattresses; keeping cribs free of stuffed animals, toys, and extra bedding; avoiding overheating; and making sure there is no smoking in the room where the baby sleeps.[1] These recommendations apply to healthy preterm infants, as well as term infants. A recent survey suggests, however, that infants discharged from an neonatal intensive care unit (NICU) were less likely to be placed on their backs for sleep by parents and other caregivers.[1] This is of significant concern because preterm infants are at higher risk for SIDS and are at risk for a longer time -- up to 6 weeks longer for the very preterm infant.[2]

Parents and caregivers must be educated regarding these practices prior to their baby's discharge from the NICU. Discharge teaching should include a thorough review of the most up-to-date recommendations. It is important to provide information not only to parents, but also to grandparents and others who may be caring for the infant. The National Institute of Child Health and Human Development[3] has information and publications that can be downloaded from their Web site and provided to parents and caregivers. Gracey[4] also provides a teaching guide that nurses can use to review the principles of safe sleep with parents.

However, in addition to providing written and verbal information, it is essential to model safe sleeping practices in the NICU. By the time they have been weaned to open cribs or bassinets, infants should be positioned exclusively on their backs unless there are clear medical reasons for certain babies to be positioned prone. Toys and other items should not be placed in cribs, nor should sheepskins, blanket rolls, nesting materials, or soft bedding be used. The practice of placing a blanket over the top of the crib to block out stimuli, common in many NICUs, should be avoided. Remember that parents will do what they see nurses and staff members doing in the NICU.

The goal is to ensure that infants are back sleeping well before discharge home.[3] Identifying a particular weight or gestational age at which infants should be shifted to back sleeping may encourage staff to remember to make this transition. A sign or other visual reminder on the crib will help staff and parents remember to place the infant on his or her back. When developing a policy for the NICU it may be helpful to identify the medical indications that may require some infants to be positioned prone rather than supine. Examples may include spinal defects, and conditions such esophageal atresia or Pierre Robin syndrome, which may compromise the airway or cause feeding problems. Infants with severe gastroesophageal reflux may also require positioning on their stomachs for periods of time.

Co-bedding of multiples, when twins, triplets, or more siblings share a crib, is a common practice in many NICUs. While some have suggested that co-bedding is developmentally beneficial, there are no randomized controlled trials that demonstrate clear benefits or risks of co-bedding. The American Academy of Pediatrics does not specifically address NICU co- bedding of twins or other multiples. However, their general recommendations are clear -- it is not safe for infants to share beds with adults or other children. Unfortunately, co-bedded infants are often placed in side-lying or prone positions, in close proximity to one another. Given the risks of overheating, entanglement with bedclothes or with one another, co-bedding of multiples should be discouraged until proven to be safe. The National Association of Neonatal Nurses Policy Statement on Co-Bedding of Twins or Higher Multiples states that the practice should only take place where clinical evaluation protocols have been established to look at safety and efficacy.[5]

The American Academy of Pediatrics has recently reported that the use of pacifiers may decrease the risk of SIDS, although the mechanism of this protective effect is not yet known. Parents should be encouraged to establish breastfeeding before introducing a pacifier at around 1 month of age.[1]

Remember that actions speak louder than words. Providing current information and modeling safe sleep practices in the intensive care nursery can help further reduce the incidence of SIDS.


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