Safe sleeping

Introduction

Infants are unable to control their sleeping environment. Providing a safe sleeping environment is the best way to reduce the risk of Sudden Unexpected Death in Infancy (SUDI). SUDI is a broad term that includes all sudden and unexpected deaths of infants less than 12 months old – this current definition includes sudden infant death syndrome (SIDS) and deaths caused by asphyxia or of an undetermined cause after a thorough investigation. SUDI remains the leading cause of infant death, with the peak age being between two and four months of age.

Infants who require care in hospital are considered to have an increased vulnerability to SUDI. Parental or caregiver home practices are influenced by what has been observed during inpatient admissions during the neonatal stage. Infants who have had altered sleeping positions, due to medical needs, need time to become accustomed to sleeping supine. It is imperative that nurses teach and model recommended infant sleep practices before discharge to reduce the incidence of SUDI. This guideline applies to all neonates and infants receiving care at The Royal Children’s Hospital.

Aim

Is to provide guidance to nursing staff on safe sleeping principles for neonates and infants receiving care at the Royal Childrens Hospital.

Outside of the Intensive Care environment, all infants are to be slept in a safe environment according to the SUDI recommendations whilst an inpatient at The Royal Children’s Hospital.
Parents or caregivers receive consistent accurate education and observe recommended practices role modelled by healthcare professionals prior to discharge.

Definition of Terms

Inclined sleep: use of hospital cot mechanism to incline the cot surface.
Mechanical ventilation: when mechanical means/machines are utilised to assist or replace spontaneous breathing of a patient.
Nest: positioning an infant to promote comfort and development using linen to create a confined space.
Prone sleeping: infant positioned sleeping on their front/face down.
Sudden Unexpected Death in Infancy (SUDI): infant death including those of undetermined cause after investigation and those caused by asphyxia.
Supine sleeping: infant positioned sleeping on their back.

Assessment

Risk Factors

There are multiple risks factors associated with SUDI:

Infant: born prematurely, low birth weight, being a twin, requiring a neonatal hospital admission.
Parental: mother less than 20 years of age, poor antenatal care, abuse of alcohol or drugs, depression or pre-existing maternal medical conditions.
Environmental: low socio-economic group, exposure to cigarette smoking.
Modifiable risks: sleep position and sleep environment.

Management

Risk reduction strategies to promote safe sleeping:

Place infant on back to sleep
Separate sleep environment
Provide a safe sleep environment
Keep infant smoke free
Pacifier/dummy use

1. Place infant on back to sleep

Infants should be slept supine as soon as they are able to tolerate lying on their backs. Sleeping supine protects the infant's airway when asleep.

There may be certain medical conditions that require an infant to sleep in different positions, such as prone or an inclined supine position. This must ONLY be done with the instruction of the treating medical team. The aim is always to have the infant sleep in a flat, supine position as soon as able.

Unwell infants are occasionally nursed in the prone position to improve ventilation and lung mechanics; these infants will have continuous cardio-respiratory monitoring and constantly be observed by a nurse. Infants should NOT be nursed prone without continuous monitoring and supervision. This should be explained to parents as a temporary measure while their child is unwell and should not be mimicked at home.

2. Separate sleep environment

Bed sharing and sleeping on the same surface are not recommended methods of safe sleeping and is not recommended or encouraged whilst in hospital. Twin/multiples co-sleeping is not recommended and should not be encouraged/facilitated in the hospital environment. In the community, it is recommended that infants sleep in their own cot, in the same room as their parents or caregivers until 6 months.

3. Provide a safe sleep environment

In an intensive care environment, there will be times where an inclined cot surface and nests are used for infants that are sedated/require mechanical ventilation. These interventions have been shown as developmentally supportive measures for periods of stress, to avoid energy expenditure, reduce unnecessary movements and assist in the weaning of analgesia. 

Where possible, all cots should remain flat. There has been no evidence to suggest that cot elevation for babies with gastroesophageal reflux (GOR) has any benefit in reducing symptoms and does not outweigh the risk of SUDI.
Infants should be slept on a firm mattress covered with a single thickness sheet with no additional padding
Infants and babies should be slept with their feet at the end of the bed.
Blankets should be firmly tucked in to the sides of the cot and to the height of the chest of the baby.
There should be no toys, pillows or bumpers in the cot. Nests should be removed as soon as developmentally suitable and replaced with swaddling.
Whilst in hospital, infants nursed on an air mattress require cardio-respiratory monitoring and constant nurse observation.
Ensure the infant’s head and face remain uncovered during sleep. An infant should NOT be put to sleep with a hat as this poses a risk for suffocation. If an infant requires a hat to maintain temperature consistently, reconsider the suitability of the infant being in an open cot.
Infants are not to be put to sleep and left unattended in prams or bouncers/swings.

4. Keep infant smoke free

Smoking remains one of the most important modifiable risk factor in reducing the risk of SUDI. Infants who are exposed to tobacco smoke before and after birth are at an increased risk of SUDI.

Educate parents on the risk between smoking and SUDI
Breast-feeding has been shown to be protective against SIDS throughout infancy. Mothers who smoke are still encouraged to breast feed their children as studies found increased nicotine levels in babies of mothers who report smoking during pregnancy compared to babies of non-smoking mothers, were a result of passive smoking rather than transfer via breast milk.
Document family smoking history on admission and refer parents to smoking cessation programs to ensure they have adequate support if they choose to cease smoking.

5. Pacifier/dummy use

In an inpatient setting, consent from parents must be obtained prior to offering an infant a pacifier/dummy. This should be documented in the patients EMR. Parents should be allowed to make an informed decision about the use of a dummy for their child.
The American Academy of Pediatrics and a review by the Johanna Brigg Institute, suggest that offering a dummy at sleep time reduces SIDS risk.

Special Considerations

Swaddling is an effective method of settling babies and helping them stay asleep. Swaddling should be assessed according to developmental stage
In the Butterfly NICU, safe sleeping practices should be implemented at least 48hrs prior to discharge home or going to Care By Parent accommodation. ‘Safe sleep’ cot signs should be utilised for these patients as a reminder for staff and parents, along with referring to SIDS safe sleeping posters displayed around the unit.
Cardio-respiratory monitoring should cease prior to discharge to promote parental confidence in the safety of sleeping in the supine position.

Family Centred Care

Hospitalisation is an opportunity to educate and model safe practice for families. In light of this, it is important to ensure open and consistent communication about sleep practices that do not reflect SIDS Safe Sleeping guidelines. Once clinical stability is established staff must ensure infants are slept in accordance to the safe sleeping strategies discussed above to demonstrate to families this is the safest way to sleep their child. Modelling correct sleep practices aims to ensure families continue this once discharge home.

Discharge Advice Summary – sleep environment

Infants should be slept exclusively in their own cot/bassinet that meets Australian standards, kept in the same room as the parents for the first 6 months.
Infants should be placed on their back, swaddled or in a sleeping bag with all covers tucked firmly into cot
In the instance of intention to co-sleep at home parents should be advised to sleep the infant on the outside edge of the bed and not between two people or pets.
Adult bedding and pillows should be moved away from the infant.
The bed should be moved away from the wall to prevent the infant from getting trapped between the bed and the wall. The mattress can be placed on the floor to reduce the risk of injury to the infant.
At home the baby’s cot should be away from blinds/curtains/electrical appliances. The infant should NOT be slept with an electric blanket or directly near a heater.
Home monitors/ baby breathing monitors should not be used instead of following safe sleeping practices.

Discharge Advice Summary - Strategies to reduce infant exposure to smoke

Smoke after and not before feeding or holding the infant
Advise a change of clothing to remove nicotine and toxin contamination
Keep the house and car smoke free
Designate outside smoking areas that are away from doors and windows

Discharge Advice if using a dummy when putting the infant down to sleep:

Do not re-insert once the infant is asleep.
Do not force the infant to use a dummy.
The dummy should not be held in place with a face washer/cloth/toy. These pose a suffocation risk.
Do not sleep the infant with dummies that attach to their clothing/around their necks due to strangulation risks.

Companion Documents

Evidence Table

Reference	Source of Evidence	Key findings and considerations
Abdeyazdan, Z., Mohammadian-Ghahfarokhi, M., Ghazavi, Z. and Mohammadizadeh, M. (2016) Effects of nesting and swaddling on the sleep duration of premature infants hospitalized in neonatal intensive care units. Iranian journal of nursing and midwifery research, 21(5), pp. 552-556.	Clinical Trial	Clinical trial 42 Infants Swaddling and nesting are considered supportive developmental care measures. Developmental supportive positions help avoid energy expenditure caused by unnecessary movements of the infant and reduce unnecessary and excess sedation and help wean from analgesia.
Baddock, S. A., Purnell, M. T., Blair, P. S., Pease, A. S., Elder, D. E. and Galland, B. C. (2019) The influence of bed-sharing on infant physiology, breastfeeding and behaviour: A systematic review. Sleep Medicine Reviews, 43, pp. 106-117	Systematic Review	Bed-sharing between infants and parents has been identified in potentially adverse circumstances and as an increased risk for SUDI/SIDS. There are also positive benefits to the infant and parents through bed sharing. There are cultural and value based social norms in areas where SIDS rates a low and parents choose to bed share. Health professionals should provide up to date evidence about advantages and risks to facilitate parental decisions.
Buccini, G. d. S., Pérez-Escamilla, R., Paulino, L. M., Araújo, C. L. and Venancio, S. I. (2017) Pacifier use and interruption of exclusive breastfeeding: Systematic review and meta-analysis. Maternal & Child Nutrition, 13(3), pp. e12384.	Systematic Review	WHO recommendations on pacifier use. There is no general consensus on the use of pacifiers. Pacifier use can be a risk to poor breastfeeding outcomes when considering exclusive breastfeeding for the first 6 months of an infant’s life.
Friedmann, I., Dahdouh, E. M., Kugler, P., Mimran, G. and Balayla, J. (2017) Maternal and obstetrical predictors of sudden infant death syndrome (SIDS). The Journal of Maternal-Fetal & Neonatal Medicine, 30(19), pp. 2315-2323	Cohort Study	Maternal smoking remains the strongest prenatal modifiable risk factor for SIDS Recommend continuation of Public Health initiatives that promote safe infant sleeping practices and smoking cessation during and after pregnancy
Heere, M., Moughan, B., Alfonsi, J., Rodriguez, J. and Aronoff, S. (2017) Factors Associated With Infant Bed-Sharing. Global Pediatric Health, 4, pp. 2333794X17690313	Survey study of postpartum mothers	American Academy of Pediatrics advises against bed sharing as there have been strong associations with SIDS and accidental suffocation and strangulation in bed. Bed-sharing is both a risk factor for SIDS and a major barrier to safe sleep Education should address risk factors associated with infant deaths that occur during sleep. Specific support of breastfeeding without bed sharing and safe places for the infant to sleep.
Horne, R. S. C., Fyfe, K. L., Odoi, A., Athukoralage, A., Yiallourou, S. R. and Wong, F. Y. (2016) Dummy/pacifier use in preterm infants increases blood pressure and improves heart rate control. Pediatric Research, 79(2), pp. 325-332	Comparative Study	Dummy use improves cardiac control in pre term infants and thus can be a mechanism to reduce SIDS
Kahraman, A., Başbakkal, Z., Yalaz, M. and Sözmen, E. Y. (2018) The effect of nesting positions on pain, stress and comfort during heel lance in premature infants. Pediatrics & Neonatology, 59(4), pp. 352-359	Study/trial	Nesting in the prone position has a pain reducing effect, enhancing comfort and reducing stress in premature infants.
Moon.R.Y, Carin.R.F, Hand IH, Sleep-Related Infant Deaths: Updated July 2022 Recommendations for Reducing Infants Deaths in the Sleep Environment. Paediatrics, J150 (1)	Policy Statement	Pathophysiology of sleep-related deaths is complex. Risk factors outlined Summary of A level recommendations: Back to sleep for every sleep Feeding of human milk Pacifier at naptime and bedtime Avoid smoke and nicotine exposure during pregnancy and after birth Keep soft objects away Avoid overheating/ head covering Model safe sleep guidelines
Naugler, M. R. and DiCarlo, K. (2018) Barriers to and Interventions that Increase Nurses’ and Parents’ Compliance With Safe Sleep Recommendations for Preterm Infants. Nursing for Women's Health, 22(1), pp. 24-39	Review	The importance of hospitals having and implementing current, evidence based safe sleep policies. Ensure clear transitions for premature infants that have been hospitalised and ensure consistent nursing and parental education around safe sleep. One study in a hospital with a safe sleep policy- all infants transitioned to safe sleep prior to discharge. Consistent education for parents. Education for parents of premature infants should include current
Pretorius, K. and Rew, L. (2019) Sudden Infant Death Syndrome: A Global Public Health Issue and Nursing’s Response. Comprehensive Child and Adolescent Nursing, 42(2), pp. 151-160	Review article	The role of nurses in addressing safe sleeping practices
Psaila, K., Foster, J. P., Pulbrook, N. and Jeffery, H. E. (2017) Infant pacifiers for reduction in risk of sudden infant death syndrome. Cochrane Database of Systematic Reviews, (4)	Systematic review	No randomised controlled trials examining infant pacifiers for reduction in risk of SIDS.
Red Nose (Modified 2023) What is a safe sleeping bag? what is a safe sleeping bag?.	Australian Standard Recommendations	Recommendations of safe sleeping bags Ensure infant is dressed according to the room temperature. Ensure baby’s feet are at the end of the cot and the blanket can only reach as far as the baby’s chest and is tucked in firmly.
Red Nose. National Scientific Advisory Group (Updated 2022) Information Statement: Wrapping infants. https://rednose.org.au/article/wrapping-babies	Australian Standard Recommendations	Recommendations on baby wrapping for sleep. Wrapping techniques for different ages Red Nose’s six safe sleeping recommendations to reduce SUDI When to stop wrapping- there is a greatly increased risk of death if infants is swaddled rolls onto their tummy and should be ceased for sleep periods when showing signs of beginning to roll. Babies born preterm and wrapped during the period of hospitalisation have been shown to have improved neuromuscular development, better motor organisation and more self-regulatory ability.
Red Nose. National Scientific Advisory Group (NSAG) (Updated 2017) Information Statement: Smoking. https://rednose.org.au/downloads/Smoking-Safe_Sleeping-Information_Statement_Nov_2017_WEB.pdf	Australian Standard Recommendations	Recommendations around smoking and safe sleeping, smoking and breastfeeding, ways to minimise smoke exposure to infants. Strategies to reduce infant exposure- windows open, avoid smoking near baby, going outside to smoke.
Safer Care Victoria https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/infant-safe-sleeping	Recommendations	The safest place for an infants to sleep in their own cot in the same room as their parents for a minimum of 6 months. Advice for safe sleeping in Neonatal Units. Do not sleep prone unless cardiorespiratory monitoring in place. Do not elevate cot/ bassinet unless medically indicated.
World Health Organization (Accessed 30/5/24) Breastfeeding: https://www.who.int/health-topics/breastfeeding#tab=tab_1	Standard Recommendations	WHO guidelines for breastfeeding and pacifiers

Please remember to read the disclaimer

The revision of this nursing guideline was coordinated by Julia McKeown, CNS, Ally Kenrick, CNS & Narelle Miller, CNC, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2024.

The Royal Children's Hospital Melbourne

Nursing guidelines