- Email: [email protected]
An Update on Safe Infant Sleep
In Practice
An Update on Safe Infant Sleep
D
Photo in public domain / www.flickr.com/photos/mchlibrary/28681815352/
Despite known modifiable risk factors, sleeprelated infant deaths remain the leading cause of death for infants 1 to 12 months of age (Centers for Disease Control and Prevention [CDC], 2016). Although parents are often fearful and may be reluctant to discuss this topic, they rely on nurses and other health care providers to provide the information they need to keep their infants as safe as possible. Sudden unexpected infant death (SUID) is the term used in the literature for these deaths and includes
SHARON C. HITCHCOCK
sudden infant death syndrome (SIDS), accidental suffocation or strangulation in bed, and an ill-defined/unknown cause. The United States has one of the highest rates of SUID among developed nations (Taylor et al., 2015), with about 3,700 deaths in 2015 (CDC, 2016). This rate equates to approximately 10 infant deaths per day. Most of these deaths occur in unsafe sleep environments and are considered preventable (American Academy of Pediatrics [AAP], 2016; CDC, 2016).
Abstract In October 2016, the American Academy of Pediatrics published updated guidelines for safe infant sleep. Although there are no major changes to the recommendations, there are many small additions and clarifications important to the work of nurses. Topics addressed in this article include breastfeeding, skin-to-skin contact, swaddling, room-sharing, bed-sharing, new products, pacifiers, loose bedding, and sitting devices. It is important for nurses and other clinicians to model recommended behaviors with regard to safe infant sleep and to have conversations with parents and caregivers about safe infant sleep throughout the hospital stay. http://dx.doi.org/10.1016/j.nwh.2017.06.007 Keywords bed-sharing | safe infant sleep | SIDS | sudden unexpected infant death | SUID
nwhjournal.org
© 2017, AWHONN
307
In Practice
In October 2016, the AAP published updated guidelines for safe infant sleep. These recommendations are for term infants starting at birth and for preterm infants once clinically stable, and they should be followed through the first year. This article highlights key changes to the guidelines’ safe sleep recommendations. Although none of the overarching recommendations has changed substantially, the AAP offers clarification on many points, including guidance for parents facing challenges specific to bed-sharing. See Box 1 for the full list of 2016 AAP recommendations.
Positioning, Skin-to-Skin Contact, and Swaddling Back-only positioning remains the highestpriority safe sleep recommendation, including for hospitalized preterm newborns, once physiologically stable. Skin-to-skin contact is safe and recommended, ideally starting immediately after birth if the mother is awake, stable, and monitored. Once the mother becomes sleepy, however, or is distracted with other tasks, her newborn should be placed supine in the bassinet. Swaddling can be an effective way to calm a fussy infant and encourage supine sleep. It is considered safe if done correctly (see Box 2).
Despite known modifiable risk factors, sleep-related infant deaths remain the leading cause of death for infants 1 to 12 months of age
Sharon C. Hitchcock, MSN, RNC, is a faculty member in the College of Nursing at the University of Arizona in Tucson, AZ. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
308
This includes supine positioning, using a thin blanket, and careful wrapping. The blanket should not be so tight as to restrict breathing or place undue pressure on the hips, not so loose that the infant can wiggle free of the swaddle and become covered with the blanket, and wrapped no higher than shoulder level. Swaddling should be discontinued once the infant is showing signs of wanting to roll over, often as early as 2 months. Commercial swaddle sacks are acceptable. Swaddling has not been found to decrease the risk of SUID (Moon & Task Force on Sudden Infant Death Syndrome, 2016).
Nursing for Women’s Health
Breastfeeding Breastfeeding is protective and continues to be strongly encouraged, because it reduces the risk of SUID by up to 50%. Exclusive breastfeeding is best, but even some breastfeeding offers protection. Breastfeeding has become a higher priority on the 2016 list of safe sleep recommendations.
Room-Sharing, Bed-Sharing, and Solitary Sleep Room-sharing is protective and safer than solitary sleep and bed-sharing. Room-sharing reduces the risk for SUID by 50% and provides many of the same benefits of bed-sharing. It is recommended for at least the first 6 months, preferably the first year. This is a change from the previous recommendation of a full year. There is now some evidence suggesting there might be negative consequences of room-sharing, such as on sleep quality and bedtime routines after 6 months (Moon & Hauck, 2017; Paul et al., 2017). Bed-sharing is defined as sleeping together on any sleep surface such as an adult bed, couch, or recliner (AAP, 2016). This continues to be a highly controversial topic because of the practical reality of exhausted parents who need to feed their infant at night somewhere and the conflicting research that has shown benefits to bed-sharing for breastfeeding, comforting, and bonding. Although most researchers agree that the risks of bed-sharing outweigh the benefits, parents have been left with a confusing mix of advice. Further, research has shown that although some parents will purposefully bedshare, many will inadvertently bed-share, often in very unsafe locations, such as on a couch or recliner (AAP, 2016; Krouse et al., 2012; Smith et al., 2016). The AAP continues to advise against bedsharing; however, there is now an acknowledgement of the challenges many parents face. The following guidelines are for all parents, whether they are planning to bed-share or not: • Feeding a baby at night in an adult bed is safer than on a couch or recliner, both of which are extremely dangerous. • If feeding in a bed, keep all blankets, sheets, comforters, and pillows away from the baby to prevent accidental suffocation or overheating.
Volume 21
Issue 4
2016 AAP Safe Infant Sleep Recommendations 1. Use back-only positioning for all sleep. 2. Use a firm sleep surface in a safetyapproved crib, play yard, or bassinet.
12. Avoid monitors or devices marketed to reduce the risk of SIDS.
In Practice
Box 1.
3. Breastfeeding is protective.
13. Avoid commercial products that are inconsistent with the safe sleep recommendations.
4. Room-sharing is protective and safer than solitary sleep or bed-sharing.
14. Provide “tummy time” when the baby is awake and supervised.
5. Keep blankets, pillows, and other loose items away from sleep area.
15. Swaddling is safe if done properly but does not reduce the risk of SIDS.
6. Pacifiers are protective.
16. Health care and child care providers should endorse and model the safe sleep recommendations from birth.
7. Avoid smoke exposure during pregnancy and after the infant is born. 8. Avoid alcohol and illicit drugs during pregnancy and after the infant is born.
17. Media and manufacturers should follow the safe sleep recommendations.
9. Avoid overheating and covering the infant’s head during sleep.
18. Government entities should continue the “Safe to Sleep” public health campaign.
10. Obtain regular prenatal care.
19. Scientists should continue with research and surveillance.
11. Immunize according to current recommendations.
Source: AAP (2016).
• If the parent falls asleep while feeding, the baby should be placed back into his/ her own sleep space as soon as the parent awakens. Studies show that the longer a parent is asleep with the baby, the greater the risk of SUID. • There are specific situations that greatly increase the risk of bed-sharing and should be avoided at all times (see Box 3).
Photo © Nachosuch / iStockphoto.com
One final word on room-sharing and bedsharing: in 2013, the Consumer Product Safety Commission (CPSC) published safety standards for bedside sleepers, which are infant beds that connect to the side of the adult bed. However, in-bed sleepers, which are devices promoted to make bed-sharing “safe,” do not
Soft or loose bedding continues to be a common cause of death, especially in infants older than 3 months when they are beginning to roll over
August | September 2017
Nursing for Women’s Health
309
Box 2.
Safety Considerations When Swaddling 1. Use a thin blanket. 2. Stop at around 2 months or once infant shows signs of wanting to roll over. 3. Make sure wrap is not too tight, such as to restrict breathing or put undue pressure on hips. You should be able to slip two to three fingers under the swaddled blanket
4. Make sure wrap is not too loose, in which case the infant could wiggle free of the swaddle and become covered with the blanket. 5. Make sure the wrap is not too high. The swaddle should be no higher than shoulder level. 6. When swaddling, make sure the infant is wholly supine and in a safe sleep environment. Source: Moon and Task Force on Sudden Infant Death Syndrome (2016).
Box 3.
Circumstances in Which Bed Sharing Is Highly Dangerous 1. When the infant is younger than age 4 months
6. If the bed-sharer is not a parent
2. If the infant was born premature or had low birth weight
7. If there are multiple bed-sharers
3. If the bed-sharer is a smoker or if the mother smoked during pregnancy 4. If the bed-sharer has taken illicit drugs or medicine that causes drowsiness 5. If the bed-sharer has consumed any alcohol
8. If the sleep surface is soft, such as an old mattress, waterbed, or pillow-top mattress 9. If the sleep surface is small or a couch, sofa, or recliner 10. If there is soft bedding, such as pillows or blankets, present in the bed Source: Moon and Task Force on Sudden Infant Death Syndrome (2016).
have CPSC safety standards. Because neither of these products has been thoroughly studied, the AAP offers no advice for or against their use. Of interest, New Zealand is currently studying the use of in-bed sleepers, which could hold promise for new recommendations in the future (Cowan, Bennett, Clark, & Pease, 2013; Mitchell, Cowan, & Tipene-Leach, 2016; Moon, Hauck, & Colson, 2016).
Pacifiers Use of pacifiers is another protective recommendation, with studies now showing a 50% to 90% decrease in SUID risk with their use. Furthermore, evidence does not support the concern of an “adverse relationship between pacifier use and breastfeeding duration
310
Nursing for Women’s Health
or exclusivity” (Moon & Task Force on Sudden Infant Death Syndrome, 2016, p. e16). Infants should be offered a pacifier when placed to sleep, but it should not be forced. Breastfed babies should not be offered a pacifier until breastfeeding is well established, typically after 3 to 4 weeks.
Safe Cribs, Sitting Devices, and Other Products Soft or loose bedding continues to be a common cause of death, especially in infants older than 3 months when they are beginning to roll over. Parents should remain diligent in keeping the crib empty of all soft, loose, or fluffy items, including bumper pads, through the first year of life.
Sitting and carrying devices, such as car seats, strollers, swings, bouncers, slings, and carriers, are often used for routine infant sleep, but this is not advised (Rholdon, 2017). This practice is particularly dangerous for infants younger than 4 months of age. The AAP recommends that a sleeping infant be removed from the product and placed on an appropriate sleep surface as soon as it is safe and practical. This recommendation includes use of devices in the home and in the hospital. Wedges, positioners, breathable mattresses, and other devices that claim to reduce the risk of SUID should be carefully investigated before use for inconsistencies with the safe sleep recommendations. For example,
Volume 21
Issue 4
Studies suggest that safe sleep education in the hospital that is started at birth, consistently modeled, continued throughout the hospital stay, and provided by multiple health care providers is more effective than traditional discharge teaching
wedges and positioners have been implicated in suffocation and entrapment deaths, and the CPSC warns against their use. Breathable mattresses have not been shown to reduce the risk of SIDS but might be a safe alternative to a traditional mattress as long as they meet all safe sleep recommendations, such as for firmness and with no gaps between the mattress and crib walls. Positioners and other devices used for physical therapy within the hospital setting should be discontinued well before discharge.
Nurses Modeling and Teaching With a Conversational Tone Nurses should model and endorse all safe sleep recommendations. When a recommendation cannot be followed, such as when preterm infants are positioned on their stomachs, the reason should be provided to parents. Studies suggest that safe sleep education in the hospital that is started at birth, consistently modeled, continued throughout the hospital stay, and provided by multiple health care providers is more effective than traditional discharge teaching (Salm Ward & Balfour, 2016). The AAP further recommends that organizations create safe sleep policies in an effort to produce uniform practice among all health care providers. Finally, because of the controversy and complexity of the recommendations, the topic of safe infant sleep should be raised with parents in a nonthreatening, conversational tone, allowing time for parents to ask questions, reflect, and problem-solve with their nurse (AAP, 2016; Salm Ward & Balfour, 2016).
August | September 2017
Conclusion Safe infant sleep has proven to be extraordinarily complex. The sheer volume, complexity, and controversy surrounding safe sleep recommendations can make the topic a challenge for even the most experienced nurse. Education, however, is key, and nurses’ modeling of and teaching of recommended behaviors is critical to helping parents understand and adhere to the recommendations. Ultimately, the goal is to eliminate sleep-related infant deaths entirely (AAP, 2016), and the recent changes to the guidelines have great potential to help make this important but challenging topic just a little bit easier. NWH
References American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938 Centers for Disease Control and Prevention. (2016). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www .cdc.gov/sids/index.htm Cowan, S., Bennett, S., Clark, J., & Pease, A. (2013). An evaluation of portable sleeping spaces for babies following the Christchurch earthquake of February 2011. Journal of Paediatrics and Child Health, 49(5), 364–368. doi:10.1111/ jpc.12196 Krouse, A., Craig, J., Watson, U., Matthews, Z., Kolski, G., & Isola, K. (2012). Bed-sharing influences, attitudes, and practices: Implications
for promoting safe infant sleep. Journal of Child Health Care, 16(3), 274–283. doi:10.1177/1367493511432300 Mitchell, E. A., Cowan, S., & TipeneLeach, D. (2016). The recent fall in postperinatal mortality in New Zealand and the safe sleep programme. Acta Paediatrica, 105(11), 1312–1320. doi:10.1111/apa.13494 Moon, R. Y., Hauck, F. R., & Colson, E. R. (2016). Safe infant sleep interventions: What is the evidence for successful behavior change? Current Pediatric Reviews, 12(1), 67–75. doi:10.2174/5733 96311666151026110148 Moon, R. Y., & Hauck, F. R. (2017). Are there long-term consequences of roomsharing in infancy? Pediatrics, 140(1), 1–4. doi:10.1542/peds.2017-1323. Moon, R. Y., & Task Force on Sudden Infant Death Syndrome. (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleep environment. Pediatrics, 138(5), e1–e34. doi:10.1542/peds.2016-2940 Paul, I. P., Hohman, E. E., Loken, E., Savage, J. S., Anzman-Frasca, S., Carper, P., . . . Birch, L. L. (2017). Mother-infant room-sharing and sleep outcomes in the INSIGHT study. Pediatrics, 140(1), 1–23. doi:10.1542/peds.2017-0122. Rholdon, R. (2017). Understanding the risks sitting and carrying devices pose to safe infant sleep. Nursing for Women’s Health, 21(3), 225–230. doi:10.1016/j. nwh.2017.04.006 Salm Ward, T. C., & Balfour, G. M. (2016). Infant safe sleep interventions, 1990–2015: A review. Journal of Community Health, 41(1) 180–196. doi:10.1007/s10900-015-0060-y Smith, L. A., Geller, N. L., Kellams, A. L., Colson, E. R., Rybin, D. V., Heeren, T., & Corwin, M. J. (2016). Infant sleep location and breastfeeding practices in the United States, 2011–2014. Academic Pediatrics, 16(6), 540–549. doi:10.1016/j.acap.2016.01.021 Taylor, B. J., Garstang, J., Engelberts, A., Obonai, T., Cote, A., Freemantle, J., . . . Moon, R. Y. (2015). International comparison of sudden unexpected death in infancy rates using a newly proposed set of cause-of-death codes. Archives of Disease in Childhood, 100(11), 1018–1023. doi:10.1136/ archdischild-2015-308239
Nursing for Women’s Health
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An Update on Safe Infant Sleep
D
Photo in public domain / www.flickr.com/photos/mchlibrary/28681815352/
Despite known modifiable risk factors, sleeprelated infant deaths remain the leading cause of death for infants 1 to 12 months of age (Centers for Disease Control and Prevention [CDC], 2016). Although parents are often fearful and may be reluctant to discuss this topic, they rely on nurses and other health care providers to provide the information they need to keep their infants as safe as possible. Sudden unexpected infant death (SUID) is the term used in the literature for these deaths and includes
SHARON C. HITCHCOCK
sudden infant death syndrome (SIDS), accidental suffocation or strangulation in bed, and an ill-defined/unknown cause. The United States has one of the highest rates of SUID among developed nations (Taylor et al., 2015), with about 3,700 deaths in 2015 (CDC, 2016). This rate equates to approximately 10 infant deaths per day. Most of these deaths occur in unsafe sleep environments and are considered preventable (American Academy of Pediatrics [AAP], 2016; CDC, 2016).
Abstract In October 2016, the American Academy of Pediatrics published updated guidelines for safe infant sleep. Although there are no major changes to the recommendations, there are many small additions and clarifications important to the work of nurses. Topics addressed in this article include breastfeeding, skin-to-skin contact, swaddling, room-sharing, bed-sharing, new products, pacifiers, loose bedding, and sitting devices. It is important for nurses and other clinicians to model recommended behaviors with regard to safe infant sleep and to have conversations with parents and caregivers about safe infant sleep throughout the hospital stay. http://dx.doi.org/10.1016/j.nwh.2017.06.007 Keywords bed-sharing | safe infant sleep | SIDS | sudden unexpected infant death | SUID
nwhjournal.org
© 2017, AWHONN
307
In Practice
In October 2016, the AAP published updated guidelines for safe infant sleep. These recommendations are for term infants starting at birth and for preterm infants once clinically stable, and they should be followed through the first year. This article highlights key changes to the guidelines’ safe sleep recommendations. Although none of the overarching recommendations has changed substantially, the AAP offers clarification on many points, including guidance for parents facing challenges specific to bed-sharing. See Box 1 for the full list of 2016 AAP recommendations.
Positioning, Skin-to-Skin Contact, and Swaddling Back-only positioning remains the highestpriority safe sleep recommendation, including for hospitalized preterm newborns, once physiologically stable. Skin-to-skin contact is safe and recommended, ideally starting immediately after birth if the mother is awake, stable, and monitored. Once the mother becomes sleepy, however, or is distracted with other tasks, her newborn should be placed supine in the bassinet. Swaddling can be an effective way to calm a fussy infant and encourage supine sleep. It is considered safe if done correctly (see Box 2).
Despite known modifiable risk factors, sleep-related infant deaths remain the leading cause of death for infants 1 to 12 months of age
Sharon C. Hitchcock, MSN, RNC, is a faculty member in the College of Nursing at the University of Arizona in Tucson, AZ. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
308
This includes supine positioning, using a thin blanket, and careful wrapping. The blanket should not be so tight as to restrict breathing or place undue pressure on the hips, not so loose that the infant can wiggle free of the swaddle and become covered with the blanket, and wrapped no higher than shoulder level. Swaddling should be discontinued once the infant is showing signs of wanting to roll over, often as early as 2 months. Commercial swaddle sacks are acceptable. Swaddling has not been found to decrease the risk of SUID (Moon & Task Force on Sudden Infant Death Syndrome, 2016).
Nursing for Women’s Health
Breastfeeding Breastfeeding is protective and continues to be strongly encouraged, because it reduces the risk of SUID by up to 50%. Exclusive breastfeeding is best, but even some breastfeeding offers protection. Breastfeeding has become a higher priority on the 2016 list of safe sleep recommendations.
Room-Sharing, Bed-Sharing, and Solitary Sleep Room-sharing is protective and safer than solitary sleep and bed-sharing. Room-sharing reduces the risk for SUID by 50% and provides many of the same benefits of bed-sharing. It is recommended for at least the first 6 months, preferably the first year. This is a change from the previous recommendation of a full year. There is now some evidence suggesting there might be negative consequences of room-sharing, such as on sleep quality and bedtime routines after 6 months (Moon & Hauck, 2017; Paul et al., 2017). Bed-sharing is defined as sleeping together on any sleep surface such as an adult bed, couch, or recliner (AAP, 2016). This continues to be a highly controversial topic because of the practical reality of exhausted parents who need to feed their infant at night somewhere and the conflicting research that has shown benefits to bed-sharing for breastfeeding, comforting, and bonding. Although most researchers agree that the risks of bed-sharing outweigh the benefits, parents have been left with a confusing mix of advice. Further, research has shown that although some parents will purposefully bedshare, many will inadvertently bed-share, often in very unsafe locations, such as on a couch or recliner (AAP, 2016; Krouse et al., 2012; Smith et al., 2016). The AAP continues to advise against bedsharing; however, there is now an acknowledgement of the challenges many parents face. The following guidelines are for all parents, whether they are planning to bed-share or not: • Feeding a baby at night in an adult bed is safer than on a couch or recliner, both of which are extremely dangerous. • If feeding in a bed, keep all blankets, sheets, comforters, and pillows away from the baby to prevent accidental suffocation or overheating.
Volume 21
Issue 4
2016 AAP Safe Infant Sleep Recommendations 1. Use back-only positioning for all sleep. 2. Use a firm sleep surface in a safetyapproved crib, play yard, or bassinet.
12. Avoid monitors or devices marketed to reduce the risk of SIDS.
In Practice
Box 1.
3. Breastfeeding is protective.
13. Avoid commercial products that are inconsistent with the safe sleep recommendations.
4. Room-sharing is protective and safer than solitary sleep or bed-sharing.
14. Provide “tummy time” when the baby is awake and supervised.
5. Keep blankets, pillows, and other loose items away from sleep area.
15. Swaddling is safe if done properly but does not reduce the risk of SIDS.
6. Pacifiers are protective.
16. Health care and child care providers should endorse and model the safe sleep recommendations from birth.
7. Avoid smoke exposure during pregnancy and after the infant is born. 8. Avoid alcohol and illicit drugs during pregnancy and after the infant is born.
17. Media and manufacturers should follow the safe sleep recommendations.
9. Avoid overheating and covering the infant’s head during sleep.
18. Government entities should continue the “Safe to Sleep” public health campaign.
10. Obtain regular prenatal care.
19. Scientists should continue with research and surveillance.
11. Immunize according to current recommendations.
Source: AAP (2016).
• If the parent falls asleep while feeding, the baby should be placed back into his/ her own sleep space as soon as the parent awakens. Studies show that the longer a parent is asleep with the baby, the greater the risk of SUID. • There are specific situations that greatly increase the risk of bed-sharing and should be avoided at all times (see Box 3).
Photo © Nachosuch / iStockphoto.com
One final word on room-sharing and bedsharing: in 2013, the Consumer Product Safety Commission (CPSC) published safety standards for bedside sleepers, which are infant beds that connect to the side of the adult bed. However, in-bed sleepers, which are devices promoted to make bed-sharing “safe,” do not
Soft or loose bedding continues to be a common cause of death, especially in infants older than 3 months when they are beginning to roll over
August | September 2017
Nursing for Women’s Health
309
Box 2.
Safety Considerations When Swaddling 1. Use a thin blanket. 2. Stop at around 2 months or once infant shows signs of wanting to roll over. 3. Make sure wrap is not too tight, such as to restrict breathing or put undue pressure on hips. You should be able to slip two to three fingers under the swaddled blanket
4. Make sure wrap is not too loose, in which case the infant could wiggle free of the swaddle and become covered with the blanket. 5. Make sure the wrap is not too high. The swaddle should be no higher than shoulder level. 6. When swaddling, make sure the infant is wholly supine and in a safe sleep environment. Source: Moon and Task Force on Sudden Infant Death Syndrome (2016).
Box 3.
Circumstances in Which Bed Sharing Is Highly Dangerous 1. When the infant is younger than age 4 months
6. If the bed-sharer is not a parent
2. If the infant was born premature or had low birth weight
7. If there are multiple bed-sharers
3. If the bed-sharer is a smoker or if the mother smoked during pregnancy 4. If the bed-sharer has taken illicit drugs or medicine that causes drowsiness 5. If the bed-sharer has consumed any alcohol
8. If the sleep surface is soft, such as an old mattress, waterbed, or pillow-top mattress 9. If the sleep surface is small or a couch, sofa, or recliner 10. If there is soft bedding, such as pillows or blankets, present in the bed Source: Moon and Task Force on Sudden Infant Death Syndrome (2016).
have CPSC safety standards. Because neither of these products has been thoroughly studied, the AAP offers no advice for or against their use. Of interest, New Zealand is currently studying the use of in-bed sleepers, which could hold promise for new recommendations in the future (Cowan, Bennett, Clark, & Pease, 2013; Mitchell, Cowan, & Tipene-Leach, 2016; Moon, Hauck, & Colson, 2016).
Pacifiers Use of pacifiers is another protective recommendation, with studies now showing a 50% to 90% decrease in SUID risk with their use. Furthermore, evidence does not support the concern of an “adverse relationship between pacifier use and breastfeeding duration
310
Nursing for Women’s Health
or exclusivity” (Moon & Task Force on Sudden Infant Death Syndrome, 2016, p. e16). Infants should be offered a pacifier when placed to sleep, but it should not be forced. Breastfed babies should not be offered a pacifier until breastfeeding is well established, typically after 3 to 4 weeks.
Safe Cribs, Sitting Devices, and Other Products Soft or loose bedding continues to be a common cause of death, especially in infants older than 3 months when they are beginning to roll over. Parents should remain diligent in keeping the crib empty of all soft, loose, or fluffy items, including bumper pads, through the first year of life.
Sitting and carrying devices, such as car seats, strollers, swings, bouncers, slings, and carriers, are often used for routine infant sleep, but this is not advised (Rholdon, 2017). This practice is particularly dangerous for infants younger than 4 months of age. The AAP recommends that a sleeping infant be removed from the product and placed on an appropriate sleep surface as soon as it is safe and practical. This recommendation includes use of devices in the home and in the hospital. Wedges, positioners, breathable mattresses, and other devices that claim to reduce the risk of SUID should be carefully investigated before use for inconsistencies with the safe sleep recommendations. For example,
Volume 21
Issue 4
Studies suggest that safe sleep education in the hospital that is started at birth, consistently modeled, continued throughout the hospital stay, and provided by multiple health care providers is more effective than traditional discharge teaching
wedges and positioners have been implicated in suffocation and entrapment deaths, and the CPSC warns against their use. Breathable mattresses have not been shown to reduce the risk of SIDS but might be a safe alternative to a traditional mattress as long as they meet all safe sleep recommendations, such as for firmness and with no gaps between the mattress and crib walls. Positioners and other devices used for physical therapy within the hospital setting should be discontinued well before discharge.
Nurses Modeling and Teaching With a Conversational Tone Nurses should model and endorse all safe sleep recommendations. When a recommendation cannot be followed, such as when preterm infants are positioned on their stomachs, the reason should be provided to parents. Studies suggest that safe sleep education in the hospital that is started at birth, consistently modeled, continued throughout the hospital stay, and provided by multiple health care providers is more effective than traditional discharge teaching (Salm Ward & Balfour, 2016). The AAP further recommends that organizations create safe sleep policies in an effort to produce uniform practice among all health care providers. Finally, because of the controversy and complexity of the recommendations, the topic of safe infant sleep should be raised with parents in a nonthreatening, conversational tone, allowing time for parents to ask questions, reflect, and problem-solve with their nurse (AAP, 2016; Salm Ward & Balfour, 2016).
August | September 2017
Conclusion Safe infant sleep has proven to be extraordinarily complex. The sheer volume, complexity, and controversy surrounding safe sleep recommendations can make the topic a challenge for even the most experienced nurse. Education, however, is key, and nurses’ modeling of and teaching of recommended behaviors is critical to helping parents understand and adhere to the recommendations. Ultimately, the goal is to eliminate sleep-related infant deaths entirely (AAP, 2016), and the recent changes to the guidelines have great potential to help make this important but challenging topic just a little bit easier. NWH
References American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938 Centers for Disease Control and Prevention. (2016). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www .cdc.gov/sids/index.htm Cowan, S., Bennett, S., Clark, J., & Pease, A. (2013). An evaluation of portable sleeping spaces for babies following the Christchurch earthquake of February 2011. Journal of Paediatrics and Child Health, 49(5), 364–368. doi:10.1111/ jpc.12196 Krouse, A., Craig, J., Watson, U., Matthews, Z., Kolski, G., & Isola, K. (2012). Bed-sharing influences, attitudes, and practices: Implications
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