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Safe Sleep Practices

Promoting safe sleep practices is a public health priority. Much research has been conducted about safe sleep practices that address sudden infant death syndrome (SIDS) and suffocation risk reduction. Simple care giving techniques can play a critical role in keeping infants safe during sleep. 

Objectives
  • Describe why safe sleep practices are important for infants.
  • Identify your role in keeping infants safe while sleeping.
  • Apply the information from this lesson to ensure that safe sleep practices are adhered to at all times.

Learn

Know

Startling Statistics

Approximately 3,600 infants die suddenly and unexpectedly each year. Sudden Unexpected Infant Death (SUID) is a term used to describe sudden and unexpected death of an infant less than 1 year of age in which the cause was not obvious before investigation. Sudden unexpected infant death includes Sudden Infant Death Syndrome (SIDS), accidental suffocation in a sleeping environment, and other deaths from unknown causes. One-half of all SUID cases are Sudden Infant Death Syndrome.

Sudden infant death syndrome (SIDS) is the leading cause of death among infants 1 month to 12 months old and is the third-leading cause overall of infant mortality in the United States.

About one in five SIDS deaths occur while an infant is being cared for by someone other than a parent. Many of these deaths occur when infants who are used to sleeping on their backs at home are then placed to sleep on their tummies by another caregiver. Infants who are used to sleeping on their backs and placed to sleep on their tummies are 18 times more likely to die from SIDS, according to the American Academy of Pediatrics.

According to the National Resource Center for Health and Safety in Child Care and Early Education, a majority of SIDS-related deaths at child-care facilities occur in the first week that an infant starts attending a child care program.

Sudden Infant Death Syndrome

Sudden infant death syndrome is defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history. Most SIDS deaths occur between 1 month and 4 months of age, however SIDS deaths can occur anytime during the first year of life.

Sudden Infant Death is NOT:

  • the same as suffocation and is not caused by suffocation
  • caused by vaccines, immunizations, or shots.
  • contagious
  • the result of neglect of abuse
  • caused by cribs
  • caused by vomiting or choking
  • completely preventable, but there are ways to reduce the risk

Because the causes of SIDS are unknown, safe sleep practices should be used to reduce the risk of SIDS in every infant under the age of 1 year.

Known Risk Factors for SIDS

The possibility of losing an infant to SIDS while they are attending your program is frightening and understanding the syndrome and the precautions that you can take to reduce the infant’s risk is critical. Currently the cause of SIDS is unknown and in most cases the infant appears healthy before death, however some infants are more at risk than others. Research indicates that several factors place infants at a higher risk for SIDS and other sleep-related deaths. For example, SIDS is more likely to occur among infants between 1 and 4 months old, is more common among boys than girls, and the most deaths occur during the fall, winter, and early spring months. Infants that are at a higher risk of dying from SIDS include those that:

  • sleep on their stomachs or side
  • sleep on soft surfaces
  • sleep with fluffy blankets or toys
  • get too hot during sleep
  • are exposed to cigarette smoke in the womb or in their environment (home, bedroom, car)
  • were born to mothers that had little to no prenatal care
  • were premature or low birth weight
  • have a sibling who died of SIDS
  • sleep in an adult bed with parents, other children, or family members
  • share a bed with an adult that smokes, has recently had alcohol, or is tired
  • shares a bed with others and is covered by a blanket
  • shares a bed with multiple people
  • shares a bed and is younger than 14 weeks of age

See

Education is the key to promoting caregiving practices that ensure infants’ well-being. The American Academy of Pediatrics (AAP) provides safe sleep policy guidelines and practices.

Encouraging Safe Sleep Practices

Watch this video to see the way one program communicated safe sleep practices.

AAP’s policy guidelines say:

  • Healthy babies should always be placed on their backs to sleep.

    Placing and infant on their back is the safest sleep position until they are 1 year old. Infants that usually sleep on their backs, but are placed to sleep on their stomachs, like for a nap, are at a very high risk for SIDS. Side sleeping is problematic because an infant can roll more easily onto their stomach. If an infant rolls over onto their stomachs on their own, adults do not need to reposition the child onto their backs. While adults are often concerned about an infant choking in this position, there is no increase in choking for babies that sleep on their backs. In fact, babies might cough up fluids better when sleeping on their backs.

    A physician’s note should be required for non-back sleepers; the note or statement should explain why the baby should not use a back-sleeping position, how the child should be placed to sleep, and a time frame for the instructions to be followed.

  • Newborns should be placed skin-to-skin for at least the first hour after birth.

    Skin-to-skin contact helps infants regulate their body temperature, stabilize their heart rate and breathing patterns, stimulates specific parts of the brain and supports successful breastfeeding which is associated with a reduced risk of SIDS.

  • Cribs must be in compliance with 2021 U.S. Consumer Product Safety Commission and ASTM International requirements.

    A crib that meets the safety standards of the Consumer Product Safety Commission (CPSC) should be used. Infants who arrive at the facility asleep in car safety seats should be immediately removed and placed on their backs in a safety approved crib. Infants should not nap or sleep in a car safety seat, bean-bag chair, bouncy seat, infant seat, swing, jumping chair, playpen or play yard, highchair, chair, futon, or any other type of furniture or equipment that is not a safety-approved crib. If an infant falls asleep in one of these, the infant should be immediately removed and be placed on their back in a safety-approved crib.

  • Use a firm crib mattress covered by a tight-fitting sheet designed for a safety-approved crib.

    Crib mattresses used should be firm and should not indent when the baby is lying on it. The crib sheet should be tight-fitting and the appropriate size for the safety-approved crib in use.

  • Keep cribs free of blankets, pillows, stuffed toys, soft objects, loose bedding and bumper pads. Nothing else should be in the crib except for the baby.

    Keeping blankets, soft toys, bumpers, or loose bedding out of the infant’s crib reduces the risk of SIDS, suffocation, entrapment, and strangulation. There is no evidence that using crib bumpers prevents injury and they are linked to suffocation, entrapment and strangulation. Evidence does not support the safety or effectiveness of wedges, positioners, or other products that claim to reduce the risk of SIDS, reflux, or suffocation.

  • Bibs, necklaces, headbands, and garments with ties or hoods must be removed.

    These items can cause suffocation, entrapment and strangulation and should be removed before putting an infant to sleep. An infant’s face and head should be kept uncovered at all times during sleep.

  • Dress the baby lightly for sleep. The room temperatures throughout the facility are set and maintained in a range that is comfortable for a lightly clothed adult.

    Ensure that infants are lightly clothed for sleeping (sleepers, sleep sacks, wearable blankets). These are designed to keep babies warm without the need for loose blankets or quilts in the sleep area. Watch for signs of overheating, such as sweating or the infant's skin feeling hot to the touch.

  • Offer pacifiers at nap and nighttime to reduce the risk of SIDS for all babies.

    Pacifiers reduce the risk of SIDS for all babies but should not be forced. If the pacifier falls out of the infant’s mouth, there is no need to put the pacifier back in. Pacifiers should not be attached to anything (clothing, blanket, stuffed toy).

  • Avoid bed-sharing.

    There is no evidence that bed sharing reduces the risk of SIDS. In fact, some studies suggest that bed sharing may actually increase the risk of SIDS. Instead, you can bring your baby’s crib into your room for the first six months so that you can more easily monitor them.

  • Make sure that your infant has a smoke-free environment.

    Avoid smoking when you are pregnant and don’t let anyone smoke near your infant. Infants and children exposed to smoke have an increased risk of SIDS and other diseases.

Continue to watch as a caregiver describes how her program ensures a safe sleep environment in her mixed-age infant toddler classroom.

Safe Sleep Practices in Mixed-Age Settings

Watch as a caregiver describes how they ensure a safe sleep environment in her mixed-age infant toddler classroom.

Supervision

Active supervision during naps is critical. Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking. The lighting in the room must allow the caregiver to see each infant's face, to view the color of the infant's skin, and to check on the infant's breathing and placement of a pacifier if used. When infants and toddlers are sleeping, mirrors or video equipment may be used to support supervision in sleeping areas, but they don’t replace direct visual or auditory supervision. A caregiver trained in safe sleep practices should be present at all times when infants sleep. This caregiver should actively supervise sleeping infants including checking to make sure the infant’s head remains uncovered at all times.

Tummy Time

As a result of being placed on their backs to sleep infants may develop a flattening of the back of the head. To minimize this, it is recommended that infants have supervised tummy time. This includes intentionally repositioning infants and placing them on their tummy for short amounts of time to play. Tummy time also encourages motor development especially the upper body muscles. During tummy time, it's important that you actively supervise the practice and never leave infants unattended. 

Tummy time is beneficial to preventing flat spots and it also supports healthy muscle development and prepares the infants for when they are able to cruise and crawl. Caregivers should provide infants (newborns to 6+ months) with tummy time at least 2 to 3 times per day for 3 to 5 minutes, increasing the amount of time as the infant becomes used to it and shows enjoyment.

To make tummy time more enjoyable, play and interact with the infant while they are awake and on the tummy. Some babies do not enjoy tummy time at first, but there are ways to play with the infant while they are on their tummy to make it a more enjoyable experience.

  • Start small by offering tummy time for short amounts of time until the infant becomes used to the position.
  • Place a toy or interesting item in reach for the infant to play with.
  • Place toys in a circle around the baby to allow the baby to scoot and reach to different points.
  • Place yourself or a toy just out of reach to get the infant to reach for you or the toy.
  • Lie on your back and place the infant on your chest to encourage the baby to lift their head to see your face.
  • Get down on the infant’s level and encourage other children to do so (while being supervised by a caregiver) to play and interact.

During tummy time, it’s important that you actively supervise the practice of never leaving infants unattended.

Promoting Safe Sleep

Parents, family members, teachers, and all adults who care for an infant should follow safe sleep practices every nap time and every sleep time. Sleeping-related preferences may be related to a family’s culture or personal preferences and beliefs and it is important that you handle these discussions sensitively. Families in your program may have questions and concerns about the safe sleep policy in your program. It is important that you understand your programs policy and can answer families’ questions and share resources with families about safe sleep practices in a respectful and culturally sensitive way. Guidelines around safe sleep practices have changed over time, and some families may have received different advice from parents, friends and other family members. Remember, that what you say to families does make a difference. When talking with families use a strengths-based approach so that they feel valued and not judged. Use open-ended questions to get the conversations started and be honest, respectful, and sensitive in your communications. Provide families A Parent’s Guide To Good Sleep (see information in Explore).

In order to ensure the safe sleep of infants and toddlers, you should be prepared to adhere to the following guidelines:

  • Know your program’s safe sleep policy and share it with families
  • Place infants on their backs to sleep every time
  • Provide firm, safety-approved crib mattresses
  • Keep soft objects and materials (toys, stuffed animals, quilts, blankets, comforters, sheepskins, and pillows) out of cribs or near sleep areas
  • Use sleep clothing (sleepers)
  • Provide daily, supervised tummy time while babies are awake
  • Teach all staff, substitutes, and volunteers about safe sleep practices
  • Keep infants’ sleep areas free from hazards such as dangling cords, electric wires and window covering cords because they present a strangulation risk
  • Intervene when you observe unsafe sleep practices
  • Remove bibs, pacifier clips, or any clothing with hoods or cords before laying an infant down
  • Put infants to sleep in safe places, never in bouncy seats, play gyms or swings

Do

Children should be placed on their backs to sleep. If children roll over onto their stomachs on their own, adults do not need to reposition the children onto their backs.

Infants who arrive at the facility asleep in car safety seats should be immediately removed and placed on their backs in a safe sleep environment.

Infants should not nap or sleep in a car safety seat, bean-bag chair, bouncy seat, infant seat, swing, jumping chair, playpen or play yard, high chair, chair, futon, or any other type of furniture or equipment that is not a safety-approved crib. If an infant falls asleep in one of these, the infant should be immediately removed and be placed on their back in a safety-approved crib.

Infants should not be swaddled according the National Health and Safety Performance Standards, 4th edition, Standard 3.1.4.2, which states “In child care settings, swaddling is not necessary or recommended, but rather one-piece sleepers should be used.” 

Explore

As stated in the Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Settings, infants who are cared for by adults other than a parent, guardian or primary caregiver are at increased risk of dying from SIDS.

Much can be gained from learning why these risks remain. Read and study the pamphlets provided here. Respond to the questions in the Safe Sleep Risk Reduction Study Guide and share your responses with your trainer, coach, or administrator.

Apply

Visit the Healthy Children website to review safe sleep practices, including the importance of tummy time during wake time as well as other resources: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx. Then read, review and consider using the Safe Sleep Posters below in your classroom.

Glossary

Aspiration:
The inhalation of food, liquid, or a foreign body into a person’s airway which results in choking or respiratory distress
Prone:
Lying face-down
Supine:
Lying on the back

Demonstrate

Why might SIDS-related deaths occur while an infant is being cared for by someone other than a parent, according to the American Academy of Pediatrics?
Which of the following is a safe-sleep practice?
Which of the following is a barrier to implementing safe sleep practices?
References & Resources

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (2019). Caring for our children: National health and safety performance standards; Guidelines for early care and education programs. (4th ed.). American Academy of Pediatrics. https://nrckids.org/CFOC

American Academy of Pediatrics. (2022). How to keep your sleeping baby safe: AAP policy explained.https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

American Academy of Pediatrics. (2022). Can SIDS be prevented?https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Sleep-Position-Why-Back-is-Best.aspx

American Academy of Pediatrics. (2022). Make baby’s room safe: Parent checklist.https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Make-Babys-Room-Safe.aspx

Centers for Disease Control and Prevention. (2020). Sudden Unexpected Infant Death and Sudden Infant Death Syndrome. http://www.cdc.gov/SIDS/index.htm

Centers for Disease Control and Prevention. (2021). SUID and SIDS: Parents and Caregivers. http://www.cdc.gov/sids/Parents-Caregivers.htm

Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, DHHS. (2012). Safe Sleep for Your Baby: Reduce the Risk of Sudden Infant Death Syndrome (SIDS) and Other Sleep-Related Causes of Infant Death (12-7040). Washington, DC: U.S. Government Printing Office. https://www.nichd.nih.gov/publications/pubs/Documents/Safe_Sleep_Baby_English.pdf

Eunice Kennedy Shriver National Institute of Child Health and Human Development. (n.d./Updated 2015, January 2). Safe to Sleep Public Education Campaign. https://safetosleep.nichd.nih.gov/

Healthy Child Care America (n.d.). HCCA Safe Sleep Campaign. American Academy of Pediatrics. http://www.healthychildcare.org/sids.html

Healthy Child Care America (n.d.). Back to Sleep, Tummy to Play [Brochure]. American Academy of Pediatrics. http://www.healthychildcare.org/pdf/SIDStummytime.pdf

Healthy Child Care America. (2017). Back to sleep, tummy to play. American Academy of Pediatrics. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Back-to-Sleep-Tummy-to-Play.aspx