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Clinical Guidelines (Nursing)

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 including performance of an autopsy and review of the circumstances of death and the clinical history. 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 are considered part of the infant population with an increased vulnerability to SIDS. 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 accustom to sleeping supine. It is imperative that nurses teach and model recommended infant sleep practices before discharge to reduce the incidence of SUDI. 


    The aims of this guideline are to: 

    • To ensure that all infants are slept in a safe environment according to the SUDI recommendations whilst an inpatient at The Royal Children’s Hospital. 
    • To ensure that all nursing staff are aware of evidence based safe sleeping practices to guide practice when nursing hospitalised infants.
    • To ensure that parents receive consistent accurate education and are able to observe recommended practices role modelled by healthcare professionals prior to discharge.
    • To support parents in practising safe sleep practices after discharge.

    This guideline applies to all neonates and infants receiving care at The Royal Children’s Hospital. 

    Definition of Terms 

    • SUDI: Sudden unexpected death in infancy 
    • SIDS: Sudden infant death syndrome. 
    • Supine sleeping: position sleeping on their back.
    • Prone sleeping: position sleeping on their front/face down
    • Nest: positioning an infant to promote comfort and development using linen to create a confined space
    • Mechanical ventilation: or assisted ventilation is when mechanical means/machines are utilised to assist or replace spontaneous breathing of a patient when they are unable to. 

    Risk Factors

    There are multiple areas that contribute to risks associated with SUDI:

    • Infant: born prematurely, low birth weight, being a twin, requiring a neonatal hospital admission
    • Parental: mother <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: sleep position and sleep environment 
    • Preventing SUDI can be achieved by encouraging and enforcing safe sleeping practices both during an infant’s admission as well as in preparation for discharge. 

    Note: There may be certain medical conditions that require an infant to be slept in different positions however this must ONLY be done with the instruction of the treating medical team.  The aim is always to have the infant sleep in a supine position as soon as able. 

    Strategies to promote safe sleeping 

    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 infants airway when asleep.
    • Unwell infants are frequently 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. 
    • Cardio-respiratory monitoring will cease prior to discharge to promote parental confidence in the safety of sleeping in the supine position. 

    2. Provide a Safe sleep environment 

    Note: In an intensive care environment there will be times where an elevated bed head and nests are used for infants that are sedated/require mechanical ventilation. These 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. They must however be removed as soon as developmentally and medically appropriate for the infant and the infant should then be slept within the recommended safe sleeping guidelines. 

    • 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 and babies should be slept with their feet at the end of the bed, sleeping towards the end of the cot. 
    • Make sure 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. As an inpatient if a baby requires a hat to maintain temperature consistently, reconsider the suitability of the baby being in an open cot, as a hat is a SUDI risk and should be able to sleep without one at home, maintaining temperature within normal ranges.
    • 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. 
    • A firm mattress covered by a sheet is the recommended sleep surface. Infants should not be slept on soft surfaces due to risk of suffocation.
    • Whilst in hospital, infants nursed on an air mattress require cardio-respiratory monitoring and constant nurse observation.
    • Nests are potential sources of airway obstruction and entrapment. When a nest is deemed necessary for infant development, cardio-respiratory monitoring is required. Nests should be removed as soon as developmentally suitable for an infant – both nesting and swaddling provide developmental supportive care and improve infant comfort and sleep. Therefore swaddling should replace nesting as soon as appropriate.  
      Infants are not to be put to sleep and left unattended in prams or bouncers. 


    • Swaddling is an effective method of settling babies and helping them stay asleep. Swaddling should be assessed according to their developmental stage;
      • 0 – 3 months; arms should be swaddled tightly with a looser swaddle around their hips
      • Around 3 months; keep arms unwrapped (as their startle reflex starts to reduce) and swaddle from shoulder height down. It is essential to stop wrapping babies when they begin to roll. Babies can be slept in a sleep safe sleeping bag (one with fitted neck and arm holes and no hood). 

    Discharge advice:

    • The ideal safe place for the infant to sleep is a safe cot; the cot must meet the Australian Standard 
    • At home the baby’s cot should be away from blinds/curtains/electrical appliances. The baby should NOT be slept with an electric blanket or directly near a heater

    3. Keep Infant Smoke Free

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

    • Document family smoking history on admission
    • Educate parents on the risk between smoking and SUDI
    • Breast-feeding has been shown to be protective against SIDS in up to 50% 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. 
    • Refer parents to smoking cessation programs and ensure they have adequate support if they choose to cease smoking habits 

    Strategies to reduce infant exposure to smoke;

    • Smoke after 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

    4. Separate Sleep Environment

    Discharge advice for parents is to have a separate sleep space for the child, proximal to them. There is currently no universal agreement in the difference between the terms co sleeping and bed sharing. Bed sharing, sleeping on the same surface, is not the recommended method of safe sleeping. Red Nose Australia and the America Academy of Pediatrics do not recommend bed sharing with infants however if parents choose to share the same sleeping surface with their infant, precautions should be taken. More information can be found on;

    Discharge advice:

    • Infants should be slept in their own cot/bassinet in the same room as the parents.
    • If one or both parents smoke, take drugs including prescription medication that induce drowsiness or feeling less aware, are over tired or have had alcohol, the infant should not be slept on the same surface.
    • Infants should not be slept on a couch.
    • Infants should be slept to the side of an adult, not in between two adults. They should not be slept with other children or pets.
    • Adult bedding and pillows should be moved away from the infant.
    • Infants should not be able to fall off the bed. 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.  

    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. There is no consensus on the use of pacifiers/dummies and the interruption of breastfeeding. The general recommendation is to introduce a pacifier or dummy once breastfeeding has been established. The World Health Organisation recommends not using of pacifiers/dummies to encourage exclusive breastfeeding for the first 6 months of an infant’s life. Parents should be allowed to make an informed decision about the use of a pacifier/dummy for their child. 

    There has been increasing evidence to suggest that the use of pacifiers/dummies protect infants from SIDS however this has not been confirmed through randomised control trials. 
    The American Academy of Pediatrics and a review by the Johanna Brigg Institute, suggest that offering a pacifier/dummy at sleep time reduces SIDS risk. Currently the reason of this intervention is unknown although, an increase in blood pressure and heart rate (cardiac control) with pacifier/dummy use has been suggested as a mechanism that lowers SIDS risks in preterm infants.

    If using a pacifier/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 pacifier/dummy. 
    • The pacifier/dummy should not be held in place with a face washer/cloth/toy. These pose a suffocation risk. 
    • Do not sleep the infant with pacifiers/dummies that attach to their clothing/around their necks due to strangulation risks.


    • 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.
    • 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.
    • 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.
    • Craig, W. R., Hanlon-Dearman, A., Sinclair, C., Taback, S. and Moffatt, M. (2004) Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database of Systematic Reviews, (4), pp. Cd003502.
    • 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.
    • Heere, M., Moughan, B., Alfonsi, J., Rodriguez, J. and Aronoff, S. (2017) Factors Associated With Infant Bed-Sharing. Global Pediatric Health,4, pp. 2333794X17690313.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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).
    • Red Nose (2018) What is a safe sleeping bag?
    • Red Nose. National Scientific Advisory Group (2017) Information Statement: Wrapping infants. (This information statement was first posted in October, 2005. Most recent version April 2017).
    • Red Nose. National Scientific Advisory Group (NSAG) (2015) Information Statement: Smoking. (The first edition of this information statement was posted in March, 2009).
    • Task Force on Sudden Infant Death Syndrome (2016) SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics,138(5), pp. e20162938.
    • World Health Organization (2020) Breastfeeding Available:

    Evidence Table

    The evidence table for this guideline can be viewed here

      Please remember to read the disclaimer

      The development of this nursing guideline was coordinated by Aaliya Fanham, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2020.