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 a neonatal unit have an increased vulnerability to SUDI. Parental home practices are influenced by what has been observed in the neonatal unit. 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
- All infants are to be slept in a safe environment according to the SUDI recommendations whilst an inpatient at The Royal Children’s Hospital.
- All nursing staff are to be aware of evidence based safe sleeping practices to guide practice when nursing hospitalised infants.
- Parents receive consistent accurate education and observe recommended practices role modelled by healthcare professionals prior to discharge.
- Support parents in practicing safe sleep practices in preparation for 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 be slept 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
In the community, it is recommended that infants sleep in their own cot, in the same room as their parents until 6 months. Bed sharing and sleeping on the same surface are not recommended methods of safe sleeping. Twin/multiples co-sleeping is not recommended
and should not be encouraged/facilitated in the hospital environment.
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. Currently the reason for this is unknown although, an increase in blood pressure and heart rate (cardiac
control) with dummy use has been suggested as a mechanism that lowers SIDS risks in preterm infants.
Family Centred Care
Hospitalisation is an opportunity to educate and model safe practice for families. Considering 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 with 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 the cot mattress.
- 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.
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.
Companion Documents
Please remember to read the disclaimer
The development of this nursing guideline was coordinated by Julia McKeown, CNS, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated July 2024.