Chapter
: Safe Sleep Practices
Reference Points








Why Are Safe Sleep Practices Important?
What are Safe Sleep Practices?
What are Not Safe Sleep Practices?
Personal Beliefs and Practices
Agency Policy
Assessing Safety and Providing Education
Documentation
Other References
Effective Date: Draft
Last Updated: 10/12/12
Why are Safe
Sleep Practices
Important




Sudden unexpected infant deaths (SUID) that occur during sleep, have
increased in incidence, particularly since 2005, both nationally and
locally, particularly those resulting from suffocation, oxygen deprivation,
and entrapment.
Most of these causes of SUID are preventable.
The risk of all sleep-related SUID can be reduced by focusing on safe
sleep environment.
The risk of sleep-related serous long-term injury, such as permanent
brain damage, from oxygen deprivation, can also be reduced by focusing
on safe sleep environment.
______________________________________________________________
Why are Safe
Sleep Practices





Safe Sleep Practices are the consistent use of evidence-based practices
for every episode of sleep for children age 12 months and younger to
decrease risk of injury and death
ABC: Simply put, the only safe practice is for an infant to always sleep
Alone, on his or her Back, in a Crib.
More specifically, Safe Sleep Practices, as recommended in 2011 by
theAmerican Academy of Pediatrics, include:
Room-sharing without bed-sharing (also known as co-sleeping):
decreases the risk of SIDS by as much as 50%. (Placement of the crib,
portable crib, play yard or bassinet close to the parents’ bed allows close
parental proximity to the infant and facilitates feeding, comforting, and
monitoring the infant, while removing the possibility of suffocation,
strangulation, and entrapment that might occur when the infant is
sleeping in the adults’ bed.)
Placement wholly on the back to sleep for every sleep, from the earliest





age, including pre-term infants, by every caregiver, until one year of
ages. (The supine, or back, sleep position does not increase the risk of
choking and aspiration, even in infants with gastro-esophageal reflux.
Once an infant can roll from supine to prone and from prone to supine,
the infant can be allowed to remain in the sleep position that he or she
assumes.)
Use of a firm sleep surface, such as a firm crib or bassinet mattress,
covered by a fitted sheet, or a portable crib/play yard that conforms to
safety standards.
Keeping all soft objects and loose bedding out of the crib. Infant sleep
clothing that is designed to keep the infant warm without the possible
hazard of head-covering or entrapment can be used. If a blanket is used,
it should be lightweight and tucked into the foot and sides of the
mattress, up to the child’s nipple line.
Avoid overheating. In general, infants should have no more than one
layer more of clothing than an adult would wear to comfortable.
Evaluate signs of overheating, such as sweating or the infant’s chest
feeling hot to touch.
No smoking in the infant’s environment.
The use of pacifiers. (It does not need to be forced, and does not need
to be re-inserted once the infant falls asleep. For breast-feeding infants,
introduce pacifiers after breastfeeding is firmly established, usually by 3
to 4 weeks of age.)
______________________________________________________________
What Are Not
Safe Sleep
Practices
There are many practices, some of which are commonly used, which increase
the risk of infant death or injury, and so, are not safe:
 Bed-sharing, with adults, or an adult, or another child, or another infant:
increases the risk of suffocation, strangulation, and entrapment. Studies
have not demonstrated any bed-sharing situations that are protective
against SIDS or suffocation. The risks substantially increase in bedsharing situations in which:
1. The infant is younger than 3 months
2. The bed is shared with multiple persons.
3. Bed-sharing is on a soft surface.
4. Bed-sharing is on a surface with soft bedding, including pillows,
heavy blankets, quilts, and comforters.
5. Bed-sharing is with someone who:
a. Is a current smoker or if the mother smoked during
pregnancy;
b. Is excessively tired;
c. Has or is using medications or substances that could
d. Is not a parent, including other children;













Placing an infant on the front, or side.
Elevating the head of the infant or sleep surface (might result in the
infant sliding toward the foot of the crib into a position that might
compromise respiration).
Use of cribs with broken or missing parts (including those that
presumably have been fixed).
Used of mattresses that are not designed for the specific product, such
that there are gaps between the mattress and the side of the crib,
bassinet, or portable crib or play yard.
Use of soft objects, pillows, pillow-like toys, comforters, quilts,
sheepskings, thick or loose mattress covers, stuffed dolls and animals,
loose sheets or blankets, and fluffy blankets.
Use of crib bumpers (increases the potential for entrapment,
suffocation, and strangulation, and there is no evidence that they
prevent injury).
Use of beds, and portable bed rails (increases the risk of entrapment,
strangulation, and suffocation).
Sleep areas with dangling cords, electric wires, and window-covering
cords (present a strangulation risk).
Sitting devices, such as car safety seats, strollers, swings, infant carriers
and infant slings. (If an infant falls asleep in a sitting device, he or she
should be moved to a crib or other appropriate flat surface as soon as is
practical. When infant slings are used for carrying, it is important to
ensure that the infant’s head is up and above the fabric, the face is
visible, and that the nose and mouth are clear of obstructions.)
The use of home cardio respiratory monitors as a strategy for reducing
the risk of SIDS (there is no evidence that they reduce such risk)
Adults falling asleep with infants in arm-chairs and couches, sometimes
while nursing (creates an extremely high risk of suffocation. Infants
should not be fed on a couch or armchair when there is a high risk that
the parent might fall asleep).
The use of pacifiers which hang around the infant’s neck, or are
attached to infant clothing, or have toys attached to them (increase risk
of strangulation and choking).
The use of devices marketed to make bed-sharing safe, or to decrease
the risk of SIDS, including in-bed co-sleepers, wedges, positioners,
special mattresses, and special sleep surfaces. (There is no evidence that
these devices reduce the risk of SIDS or suffocation, or that they are
safe.)
______________________________________________________________
Personal Beliefs
and Practices
The Department is aware that the public, and staff may engage in many
personal practices in their own families and with their own infants, or in child
care, which are contrary to the Safe Sleep Practices which are currently
uniformly recommended by:

the American Academy of Pediatrics.

the U.S. Department of Health and Human Services

the California Department of Social Services.

The Santa Clara County Office of the Medical Examiner and Coroner.

The Santa Clara County Public Health Department.

First 5 Santa Clara County.
Personal beliefs in long-standing practices which are currently considered
unsafe and reinforced by:
 Intergenerational childrearing patterns
 Cultural beliefs
 Personal positive experiences of their use without incidence of injury to
infants
 Product advertising
 Movies, television, and magazine media
Books and articles and academics supporting practices which are currently
recognized as unsafe.
______________________________________________________________
Agency Policy
While recognizing that staff may not personally adhere to some or all Safe Sleep
Practices, DFCS, as an agency dedicated to the safety of children, and having
responsibility for promoting behavior which reduces the incidence of death and
injury to children in the community, expects staff to consistently and actively
promote the use of Safe Sleep Practices by clients and caregivers of children
within the responsibility of the Department.
The situations for assessing infant safety, and providing education, in regard
To Safe Sleep Practices include:







Screening child abuse and neglect referrals concerning infants
Investigating referrals concerning infants
Dependency Investigation concerning infants
Placement of infants in out-of-home care
Provision of Voluntary and Court-Ordered Services to families with
infants
Foster Home Recruitment and Pre-Licensure
Foster Parent Training

Foster Home Licensing

Assessment of Relatives and Non-Relative Extended Family Members
(NREFM’s) for placement for infants
Assessment of Adoptive families
Services to Non-Minor Dependents
Services to Pregnant and Parenting Teens
Parent Education
Foster Home Resources and Supports





______________________________________________________________
Assessing
Safety and
Providing
Education
Social workers are to assess the safety of infants, and include Safe Sleep
Practices in those assessments, in all situations in which social work staff
interact with:
 pregnant or expectant parents,
 parents and guardians of infants,
 and caregivers or potential caregivers of infants, including foster care
providers, relatives, NREFM’s, and childcare providers.
This includes asking questions and having discussions about sleep Practices for
naps and bedtimes.
During home visits, this includes observing sleep areas and sleep practices.
Social workers are to consider Safe Sleep Practices while considering the
conclusion of allegations for neglect. Unsafe sleep practices, by themselves In
the absence of other risk factors, are insufficient to support a finding of
substantiated general neglect, but should be considered as a possible part of a
pattern of neglect.
Social workers are to consider Safe Sleep Practices when evaluating whether a
potential caregiver, whether foster home, relative, or NREFM, is capable of
meeting the health and safety needs of infants who may be placed in their care
In all such situations of interaction with caregivers of infants, social workers are
to provide information regarding Safe Sleep Practices:

Training regarding Safe Sleep Practices is incorporated into education
provided to foster parents and prospective foster parents.
 DFCS provides cards and brochures regarding Safe Sleep Practices, in
different languages, for social workers to give to all caregivers of infants
with whom they interact.
 Social workers give resources for securing safe sleep environments to
clients with infants.
The role of Resource Family Support includes reminding foster parents about
safe Sleep Practices, and to demonstrate safe sleeping arrangements. They also
give brochures and First 5 kits.
While community Care Licensing has not promulgated Safe Sleep practices as a
foster care licensing regulation, to date, Safe Sleep Practices have been
incorporated into:

Training for prospective County-licensed foster parents,

Orientation for new daycare providers,

New foster parent training for Foster Family Agencies (FFA’s).
In instances in which a foster parent refuses to use Safe Sleep Practices,
Licensing workers may take action based on failure to provide “Care and
Supervision” and/or ‘Conduct Inimical”.
______________________________________________________________
Documentation Social workers are to document:



That Safe Sleep Practices are included in their assessments of infant
safety,
That Safe Sleep Practices are included in their instructions and
information given to infant caregivers,
the infant caregiver’s response to the information given
______________________________________________________________
Other
References
Online version of: SIDS and Other Sleep-Related Infant Deaths; Expansion of
Recommendations for a Safe Infant Sleeping Environment, American Academy
of Pediatrics, along with other information and services, may be Located at:
http://pediatrics.aappublications.org/content/early/2011/10/12/peds.20112284
______________________________________________________________