Clinical Guidelines (Nursing)

Safe sleeping

  • Note: This guideline is currently under review.  

    Recommendations for the safe sleeping of infants during inpatient admission at the Royal Children’s Hospital. Including anticipatory guidance for parents preparing for infant discharge.


    Sudden Unexpected Death in Infancy (SUDI) is a broad term that includes all sudden and unexpected deaths of infants less than 12 months old, who have died in their sleep with the cause of death not initially known. Sudden Infant Death Syndrome (SIDS) is “the sudden and unexpected death of an infant under one year of age, with onset of the lethal episode apparently occurring during sleep, which remains unexplained after a thorough investigation including performance of a complete autopsy and review of the circumstances of death and the clinical history.” SIDS and fatal sleep accidents account for the majority of SUDI deaths: incidence 0.4 per 1,000 births in 2014. Any infant who requires care in a neonatal unit is considered part of the infant population with increased vulnerability to SIDS. This guideline incorporates current Australian and International research on SIDS and is consistent with the public health campaign developed by SIDS and KIDS Australia and the American Academy of Pediatrics. It is imperative that nurses teach and model recommended infant sleep practices before discharge to reduce the incidence of SIDS and fatal sleep accidents. Parental home practices are influenced by what has been observed in the nursery and infants need time to accustom to the supine sleep position. 


    The aims of this guideline are to: 

    • Provide guidelines to ensure that all infants are slept in a safe environment according to the SIDS recommendations whilst an inpatient at The Royal Children’s Hospital. 
    • To ensure that parents receive consistent accurate information that provides an opportunity for them to observe recommended safe care practices, that have been demonstrated to reduce the incidence of SIDS and fatal sleep accidents. 
    • To support parents to continue to practice safe sleep practices when they are in their home environment.
    • This guideline is intended for use by the nursing and medical staff at The Royal Children’s Hospital
    • This guideline applies to all infants receiving care at The Royal Children’s Hospital, preparing for discharge to home and infants using rooming in facilities prior to discharge
    • The recommendations shall be implemented as soon as the infant can tolerate the intervention (some babies will discharge home with alternative sleep positions and these families require additional education)

    Definition of Terms 

    • Sudden Infant Death Syndrome (SIDS) is “the sudden and unexpected death of an infant under one year of age, with onset of the lethal episode apparently occurring during sleep, which remains unexplained after a thorough investigation including performance of a complete autopsy and review of the circumstances of death and the clinical history.”
    • Fatal Sleep Accidents: preventable infant death associated with suffocation or entrapment from factors within the sleep environment.
    • Supine sleep position: baby sleeping on their back.
    • Open cots:  refer to the clear perspex infant cribs and larger infant cots NOT radiant heater beds or incubators.
    • Nest: positioning an infant to promote comfort and development using linen to create a confined space


    Risk Factors

    • Infant :< 1year of age, preterm, low birth weight, neonatal health issues, first born, mal
    • Parental: mother < 20years of age, poor antenatal care, cigarette smoking during and after pregnancy, abuse of alcohol or drugs, depression, indigenou
    • Environmental: low socio economic group, change in care practices (increased risk on weekends)
    • Modifiable: sleep position, sleep environment and reduction in exposure to cigarette smoke


    1.  Place infant on back to sleep

    • Unwell infants are frequently nursed in the prone position to improve ventilation and lung mechanics, these infants will have continuous cardio-respiratory monitoring and constant nurse observation
    • During the resolution of the infant’s acute illness, attempt the supine position whilst monitored. If not tolerated return to the prone position.
    • Continue to trial the infant in the supine position until it is tolerated.
    • All infants in open cots will be nursed supine prior to discharge from hospital
    • Cardio respiratory monitoring will cease prior to discharge to promote parent confidence in the safety of the supine position. Unless infant is going home with SpO2 monitoring


    A medical consultation with the parents is required if  a non supine position is to continue post discharge, with the aim being to return the infant to supine as soon as their condition allows, documenting on EMR as required.

    The convalescing infant will require supervised prone play time to prevent the development of plagiocephaly and encourage gross motor skills. Rotating the infants head to alternate sides will also support the developing head shape.

    2. Provide a Safe sleep environment

    • Make sure the infant’s head and face remain uncovered during sleep
    • Firm sleep surface: Infants should not be slept on sheepskins or other soft surfaces. A firm mattress covered by a sheet is the recommended sleep surface.
    • 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. All nests will be removed from the sleep environment in a timely manner; in preparation for discharge to home.
    • Prevent the infant from slipping down under the blankets
    • Cot flat
    • Position infant with ‘feet to the end of the bed’
    • Blankets firmly tucked in to the height of the chest
    • No doonas or quilts should be allowed if they cannot be firmly tucked in around the cot mattres
    • If swaddled; the wrap should come no higher than the infants shoulder; it should be firm not tight. Use a light weight material like muslin or cotton, to avoid overheating
    • Developmental consideration: if the infant is rolling (from approximately 4 months of age), swaddling is no longer appropriate due to entrapment risk.
    • Hats should not be worn, once the infant has been transferred to an open cot. If the infant requires more than a singlet, jumpsuit and one blanket for temperature control; reassess if the infant is ready for an open cot.
    • Consider the need to be returned to the incubator. Refer to Temperature management guideline
    • Infants are not to be put to sleep in prams or bouncers; these have not been designed as sleeping products and therefore no infant should be left unsupervised if they fall asleep
    • No toys in the cot; toys are to be used when the infant is awake for stimulation and interaction with parents and staff.

    Discharge advice:

    • The ideal safe place for the infant to sleep is a safe cot; the cot must meet the Australian Standard for cots (AS/NZS 2172).
    • A safe mattress is one that is the right size for the cot, is firm and in good condition.
    • Safe bedding: no lambs wool, doonas, pillows, bumpers and toys in the cot.
    • More information can be found here:

    3. Keep Infant Smoke Free

    Smoking remains the most important modifiable risk factor in reducing the risk of SIDS.

    • Document family smoking history on admission

    Educate parents on the association between the risk of cigarette smoking and SIDS.
    Refer parents and significant family members to smoking cessation programs
    Teach strategies to reduce the infant’s exposure to cigarette 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

    A separate sleep space, proximal to parents is encouraged.

    In the hospital:

    • Observation and monitoring during episodes of kangaroo care
    • Do not co-sleep twins
    • Parents to remain alert and vigilant whilst nursing infants on the couch or in armchairs

    Discharge advice:

    • Initially sleep the infant in the same room, in their own cot
    • Bed sharing is associated with an increased risk of suffocation, entrapment, falls and overheating
    • It is culturally appropriate for some infants to share sleep space with family. Nurses should ask families their intentions regarding infant sleeping prior to discharge and educate on mechanisms that enhance safety of this practice
    • If families choose to co-sleep, this should be documented by nurses in EMR prior to discharge

    The following links highlight how to discuss the risks and benefits of co-sleeping with parents:

    5. Pacifiers

    Pacifier use has been suggested to protect against SIDS and is recommended by some authoritative bodies. However this has not been fully endorsed by all.
    The American Academy of Pediatrics and a review by the Johanna Brigg Institute, suggest that offering a pacifier at sleep time reduces the SIDS risk. Currently the mechanism of this intervention is unknown.

    Use pacifier 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
    • Do not coat in any sweet solution
    • Clean the pacifier often
    • The evidence suggests to: delay the initiation of a pacifier for one month in breastfed infants to ensure breastfeeding is firmly established
    • Pacifiers must comply with Australian standards for safety (AS 243-1991)


    1. Unwell and premature infants may require a pacifier for non nutritive sucking and comfort during painful procedures
    2. Parental consent for pacifier use should be obtained

    Potential harms:

    Pacifier use maybe associated with an increased risk of otitis media, gastro intestinal infections and oral colonization with Candida species.


    • Prompts should occur at a weekly interval in EMR to assess infant readiness for the supine sleep positio
    • Documentation should occur in EMR when the infant is sleeping according to all the SIDS recommendations and parental education is complete
    • Education with family can be documented under the education tab for families

    Family Centred Care

    Respect family knowledge, values, beliefs and cultural backgrounds in the delivery of care.

    Providing families with timely, accurate and complete information enables them to participate in care and decision making.

    Anticipatory guidance provides parents with the knowledge to confidently sleep their infants according to the safe sleep recommendations and have their concerns addressed before discharge from hospital.
    The following resources can be utilized by families to help them make an informed choice around co-sleeping with their infant. There are many documented benefits as well as risks that families should be aware of. 



    • American Academy of Pediatrics. (2005). Policy Statement. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment and New variables to Consider in Reducing Risk. Pediatrics, 116 (5), 1245-1253.
    • Esposito, L., Hegyi, T., Barbara, M., & Ostfeld, M. (2007). Educating Parents about the Risk Factors of Sudden Infant Death syndrome. The Role of Neonatal Intensive Care Unit and Well Baby Nursery Nurses. Journal of Perinatal Neonatal nurses, 21 (2), 158-164.
    • Fleming, P., & Blair, P. (2002). Sudden unexpected deaths after discharge from the neonatal intensive care unit. Seminars in neonatology, 8, 159-167.Krous, H., Beckwith, J., Byard, R., Bajanowski, T., Corey, T., Cutz, E. et al (2004). Sudden infant death syndrome and unclassified infants deaths: a definitional and diagnostic approach. Pediatrics, 114 (1), 234-238.
    • Mitchell, E., Freemantle, J., Young, J., & Byard, R. (2012). Scientific consensus forum to review the evidence underpinning the recommendations of the Australian SIDS and Kids Safe Sleeping Health Promotion Programme-October2010. Journal of Paediatrics and Child Health, 48, 626-633. Doi: 10.1111/j.1440-1754.2011.02215.x
    • Raydo, L., & Reu-Donlon, C. (2005). Putting babies ‘back to sleep’ can we do better? Neonatal Network, 24 (6), 9-16.
    • Accessed 5th October 2016                               
    • Accessed 5th October 2016

    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 Emma Lowe, Registered Midwife, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2016.