Safe Sleep
Objectives
• Increase understanding of sleep-related deaths
• Describe the Triple Risk Model
• Identify modifiable/non-modifiable risks
• Understand meaning of “Alone, Back, Crib”
• Motivate integration of Safe Sleep into nursing
practice
SIDS
Sudden Infant Death Syndrome
SUID
Sudden Unexpected Infant Death
ASSB
Accidental suffocation and strangulation
in bed
All are terms to describe
sleep-related deaths
of a baby younger than 1 yr of age
Chances of these happening go down
with a few simple changes
in how babies sleep
1983-1992 5,000-6,000 SIDS deaths/yr
1992 American Academy of Pediatrics
recommended infants <1 yr be
placed to sleep on back or side
1996 Recommendation changed to sleep
only on back
Since babies have been put to sleep
on their backs
SIDS deaths have ’d by 50%
However
putting babies on their backs
has not been enough
to prevent sleep-related deaths
There are other risks
Some are modifiable
Some are non-modifiable
#1
#2
#3
#1 Vulnerable Infant
Some babies are more likely to die from SIDS
because of abnormal control of:
- Blood pressure
- Heart rate
- Respiration
- Chemoreception
- Upper airway reflexes
- Thermoregulation
Non-modifiable Risk Factor
#1 Vulnerable Infant
Prematurity and Low birth weight
SIDS risk:
 with  birth wt and  gestational age
Non-modifiable Risk Factors
#1 Vulnerable Infant
Race
African American infants >2x more
SIDS than Caucasian infants
American Indian infants
>3x more SIDS than
Caucasian infants
Non-modifiable Risk Factor
#2 Critical Developmental
Period
Rapid growth and development of brain
in 1st year of life
Autonomic function reorganization
Learned protective behaviors
Non-modifiable Risk Factor
#3 External Stressor/s
We can’t control whether a baby is a
“vulnerable infant” or whether a baby is
in a “critical developmental period”
However
We CAN control external stressors
ALL are modifiable
#3 External Stressor/s
Second-hand Smoke
#3 External Stressor/s
Follow ABC’s of Safe Sleep
Alone
Back
Crib
Alone
The competition we’re up against
This is what we’re asking parents to do
NO
Pillows
Loose blankets
Stuffed toys
Bumper pads
This is no longer acceptable
A blanket can become a suffocation hazard
If you need to use a blanket use it
“Feet to Foot”
Like this
Not this
Yes! to Blanket Sleepers
After 37 weeks and prior to discharge
swaddling with a blanket during sleep
is not recommended
Swaddling
34-37 weeks gestation:
- Swaddle with one blanket below the arms
- If second blanket is needed for thermal support,
place it no higher than baby’s chest and tuck it
around crib mattress
What about the baby with poor
upper body tone?
May need to be swaddled from mid-arms
down to help bring arms to midline
Good Rules of Thumb
Room temperature
should be comfortable for
a lightly clothed adult
~ 72 degrees
Dress baby in no
more than one layer
than you are dressed
A well-fitting hat is OK for
thermoregulation for preterms
This
Not this
Remove for sleep at 37 wks or prior to discharge
This might look cozy
But it is DANGEROUS!
Danger of entrapment and suffocation
Extremely high risk of death
on couches and armchairs
Parents should not feed their baby on a couch or
armchair if there is a chance of falling asleep
Baby should sleep alone
Baby may be in parent’s bed for feeding or comforting
but should be returned to his/her own bed
when parent is ready to return to sleep
Billboards in Milwaukee, WI
“Your baby sleeping with you can be just as dangerous”
Alone but IN room with mother is best
Back
Every baby should be placed
“back to sleep”
Every sleep by Every caregiver
for the 1st year of life
But babies sleep better
on their stomachs!
Yes, they do
But that is why they are more likely
to die!
Prone position can result in:
’d re-breathing of carbon dioxide
’d stimulation of laryngeal receptors
causing apnea
’d efficient loss of heat
’d arousal
What about spitting up?
In prone position milk may pool in the hypopharynx
*Less likely to choke in supine position*
Guidelines for premature infants born at
< 34 weeks who are medically stable
By 32-34 weeks gestation:
Begin transition to supine sleeping in a flat
bed without nests, pillows or developmental
supports
By 34 weeks gestation or when
successfully weaned to an open crib:
Infant should sleep supine, without nests or
developmental supports and with head of bed flat
What about a baby with reflux?
 head of bed does NOT  reflux
 head of bed may result in baby
sliding  and compromising airway
However:
- Do feed in an  position
- Do hold in  position or keep
head of bed  for 30 min after feeds
Exceptions to this?
• Babies with life-threatening airway issues
(e.g. laryngeal cleft…)
• Babies with impaired airway protective
mechanisms (e.g. paralyzed vocal cord…)
• Babies with aspiration related to reflux
• Babies awaiting anti-reflux surgery
What about positioning devices?
None have been approved
But what about positioning devices for
our < 32 wk preemies and sick babies?
Yes! We can use them!
Safe Sleep guidelines are for medically stable babies
What about delayed upper
body development?
Upper body strength will be met with
a total Tummy Time of at least 1hr/day
Tummy Time when awake and alert
What about flat spots on
a baby’s head?
•
Tummy Time helps to reduce flat spots
•
Changing the direction a baby sleeps in
reduces flat spots
Flat spots usually resolve in a few
months after a baby learns to sit up
What about a bald spot?
Consider a bald spot on the back of a baby’s head
a sign of a healthy baby!
Once an infant can roll from
supine to prone and from prone to supine,
infant can be allowed to remain in the
sleep position that he or she assumes
Crib
Firm mattress covered by a fitted sheet
Crib
Pac and Play
What about swings, bouncy seats…?
Should not be used for sleeping
If an infant falls asleep in one, he or she
should be removed and placed in their bed
soon as it is practical
Exceptions to Safe Sleep:
** Must have a physician or NNP order
documenting exception and indication for exception
Example: may have head of bed up 30◦
- infant with aspiration noted on milk scan
Example: may sleep in swing
- infant with Neonatal Abstinence Syndrome (NAS)
Prior to discharge:
- Attempt should be made to assess infant’s ability to
eliminate exception(s) and follow all Safe Sleep
environment recommendations
- If infant continues to need any exception(s) to Safe
Sleep recommendations these should be fully
discussed and planned for at time of discharge
Are there other things
that might protect babies from
sleep-related death?
Protective effect of a dry pacifier
This
Not this
Not these either
Some guidelines for pacifiers:
- Offer pacifier, but don’t force it
- If pacifier falls out while baby is asleep
do not replace it
- Wait until breastfeeding is well established
before offering pacifier
Two more things that protect babies from
SIDS
Breastfeeding
Immunizations
Breastfed babies have fewer infections
Some babies who died of SIDS had recent infections
before they died
Immunizations
Immunizations cut a baby’s risk of SIDS almost in half
So what can we do?
Safe Sleep needs to start with us!
We need to teach parents Safe Sleep
We need to model Safe Sleep
Transition process in the NICU
Prone  Supine
Supported  Unsupported Positioning
“ILL” status  “HEALTHY” status
Summary
• Triple Risk Model
- Vulnerable infant
- Critical Developmental Period
- Outside stressor/s
• Alone, Back, Crib
• Use of dry pacifier, breastfeeding, immunizations
• Role modeling for families
Safe Sleep
Safe Sleep
STANDARD OF CARE
References
American Academy of Pediatrics, Task Force on
Infant Sleep Position and Sudden Infant Death
Syndrome. Changing concepts of sudden infant
death syndrome: implications for infant sleeping
environment and sleep position. Pediatrics.
2000;105:650–656
http://pediatrics.aappublications.org/content/105/3/6
50.full.html
References
Eunice Kennedy Shriver National Institute of Child
Health and Human Development, NIH, DHHS.
(2007).
Curriculum for Nurses: Continuing Education
Program on SIDS Risk Reduction (06-6005).
Washington, DC: U.S. Government Printing Office
http://www.nichd.nih.gov/publications/pubs_details.
cfm?from=&pubs_id=5685
References
Filiano, JJ, Kinney, HC. A perspective on
neuropathologic findings in victims of the sudden
infant death syndrome: the triple risk model. Biolol
Neonate. 1994;65(3-4):194-197.
Ibarra, B. Family Teaching Toolbox: A Parent’s
Guide To A Safe Sleep Environment. Advances in
Neonatal Care. 2011; 11 (1), p 27-28
References
Moon, RY, Fu, L. (2012). Sudden infant death
syndrome: an update. Pediatrics in Review. DOI:
10.1542/pir.33-7-314
Task Force on Sudden Infant Death Syndrome. SIDS
and other sleep- related infant deaths: Expansion of
recommendations for a safe infant sleeping
environment. Pediatrics. 2001;128 (5) e1341-e1367.
http://pediatrics.aappublications.org/content/128/5/e13
41.full