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    Objectives
    • Teach staff members your program’s policies related to safe-sleep practices for infants and young children.
    • Answer common questions staff members may have about SIDS and safe sleep for infants and young children.
    • Observe staff members and provide feedback on sleep environments and sleep practices for infants and young children.

    Learn

    Learn

    Teach

    You play an important role in keeping children safe in your program. Although serious injury or death can occur at any age, Sudden infant death syndrome is a very real threat in programs serving infants. The rate of SIDS has decreased drastically in the U.S. This is in large part thanks to the recommendation to place all infants to sleep on their backs. This lesson will help you identify resources on training staff members about the importance of safe-sleep practices. It will also help you monitor and coach staff members around their use of these practices.

    As aPUBLIC coach, you PUBLIC may be responsible for making sure staff members receive the professional development they need to do their jobs well. This includes training on safe-sleep for infants.PUBLIC Your program may already have a required training on safe-sleep practices. You will be responsible for providing this training and maintaining records related to staff completion.

    If your program does not have required trainings or if your staff members need supplemental training, there are many resources available. The American Academy of Pediatrics offers free training materials on using safe-sleep practices. You can find Safe Sleep resources at https://www.aap.org/en-us/about-the-aap/aap-press-room/campaigns/Safe-Sleep/Pages/default.aspx. The materials include posters, videos and infographics. 

    The American Academy of Pediatrics also offers a free online course for child-care providers. It is available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-child-care/Pages/Healthy-Futures.aspx

    Provide safe-sleep training to all new infant staff, volunteers or substitutes. Your program also should have a written policy about safe-sleep practices. Make sure all families and anyone who works with infants receives a copy of this policy. You may also consider providing regular booster training to make sure staff members have current information about safe-sleep practices.

    A good training will provide the following elements:

    Rationale and background: Let staff know why they are attending the training. In this case, they have an important responsibility to ensure infants sleep safely. Provide a definition of SIDS, an explanation of why researchers think it occurs, and a description of how often it occurs.

    Prevention strategies: Describe and show research-based strategies for keeping children safe.

    Practice and application: Give staff members a chance to practice new techniques and discuss how the techniques will be used in their settings.

    If you like, you can provide a post test. This helps you know staff members have paid attention and remember important facts.

    Staff members you work with may also have questions about sleep. As you teach staff members about safe-sleep practices, take time to answer their questions. It is natural to have questions about safe-sleep practices. Guidelines have changed over time, and some staff members may have received different advice when they raised their own children. Here are common questions staff members may have. It is important to provide consistent answers to these common questions.

    “When I had my kids, they said to put babies to sleep on their sides or tummies. If I put babies on their backs, couldn’t they spit up and choke?”

    The number of SIDS deaths has decreased by 40 percent since the American Academy of Pediatrics (AAP) began recommending infants sleep on their backs (American Academy of Pediatrics, 2005). Close supervision can help you hear and see if a child is choking or gasping. If you hear these noises or see signs of choking, you should react right away. The risk of choking is not higher in infants who sleep on their backs. Infants who sleep on their tummies have 12.9 times the risk of death compared to infants who sleep on their backs (AAP, 2000).

    “Won’t the babies get cold without blankets?”

    It is important to keep the sleeping environment comfortable for a lightly dressed adult. Between 68° and 72° is optimal. It is important to make sure infants do not get overheated while sleeping. An infant with a sweaty body, face, or head is too warm. If you are concerned about an infant being cold, consider dressing the child in a footed sleeper or wearable blanket. These garments cannot cover a child’s face and cause suffocation.

    “Why can’t we use crib bumpers? I’m afraid the babies will hit their heads on the crib posts or get stuck between the slats.”

    Crib bumpers and other pillow-like items are not safe in a child’s crib. The child may become wedged against the bumper and suffocate. To prevent babies from getting stuck between the slats, make sure the cribs you use are approved by the U.S. Consumer Product Safety Commission, ASTM International, or Juvenile Products Manufacturers Association. Crib slats should be no further apart than 2 3/8 inches. Staff members need not worry that children will injure themselves by bumping against the crib. Most young infants’ movements are not strong enough to cause serious injury.

    “When babies come in asleep, it’s so much easier to leave them in their carriers. Why isn’t this safe?”

    It may seem convenient to let infants continue sleeping in their carriers, but these carriers are not approved sleep surfaces. It is simply not safe to let a child continue sleeping in an unapproved device. Remember, you are responsible for a child’s safety once a parent drops him or her off. The carrier might be overturned with the child strapped inside, or dangling toys could interfere with the child’s breathing. Children should only sleep in approved safe-sleep environments at child care. Parents or caregivers should be asked to remove their child from the carrier and place him or her in the crib. This helps reinforce to parents the importance of safe-sleep habits.

    “One of our babies will only fall asleep in a swing. Why can’t we leave him in there?”

    Like an infant carrier, a swing is not an approved sleep surface. Often these swings are located in the general play area where other mobile infants are present. There is always the risk that the child’s breathing could be impaired. It is safest to always place a sleeping child in a crib with no additional toys, blankets, mobiles, or other children. Staff members should immediately move a child who falls asleep in a swing or bouncy seat into an approved crib (AAP, 2011).

    “Families are really worried about their babies getting flat heads from sleeping on their backs. What should I tell them?”

    There is a risk that infants who sleep on their backs or spend time in infant carriers, swings, or bouncy seats may develop a flat spot on the backs of their heads. This flat spot typically goes away as children grow. There are things you and families can do to prevent the flat spot, though. Here are some ideas from the American Academy of Pediatrics (2008):

    Regularly change the direction in which baby sleeps. For example, alternate between placing the baby’s head at the foot and head of the crib.

    Regularly change the way the baby faces interesting things in the environment. Babies tend to look toward light. Change the position of the baby’s crib so the child must turn his or her head a different direction to see the light.

    Provide tummy time every day. Tummy time should only happen when the baby is awake and you are watching. The AAP recommends starting this practice as soon as the newborn comes home from the hospital and spending 3 to 5 minutes on the tummy two or three times per day. You can gradually increase this time.

    Let the baby play in lots of different positions. Hold the baby and let her or him play on the floor as much as possible. This will limit the amount of time the baby spends in carriers, car seats, swings, and other devices that put pressure on his or her head.

    If the baby takes a bottle, switch the baby to your other arm for the second half of the bottle. This is similar to a mother switching breasts during breastfeeding and distributes the pressure on a baby’s head.

    “An incoming mom in our program really wants her baby to sleep on his tummy. He was born premature, and she says he slept on his tummy in the hospital. She says he won’t sleep any other way. What should we do?”

    Inform the mother of your safe-sleep policy and provide her a written copy. Talk with her about her concerns and encourage her to talk to her pediatrician. To allow the child to sleep on his tummy, you must receive a signed waiver from the child’s doctor describing the alternative sleep position.

    Model

    You can use video to provide examples of safe-sleep environments. Here is what you might see in environments that promote safe-sleep practices for infants.

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

    Encouraging Safe-Sleep Practices

    It is important to communicate safe-sleep practices to all staff members.

    Watch this teacher describe safe sleep in multi-age classrooms.

    Safe Sleep Practices in Mixed-Age Settings

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

    Note: State requirements for sleeping in cribs or on cots vary. Follow the requirements provided by your state.

    Observe

    Following training, you will spend time in infant classrooms to make sure safe-sleep practices are in place. You can help staff use the skills they learned in training. As you visit infant programs, look for the sleeping environment and supervision strategies.

    Sleeping Environment for Infants

    Only approved cribs and mattresses are used. Mattresses should be firm and fit tightly in the cribs. Ensure that any surface used for sleeping is approved by the U.S. Consumer Product Safety Commission, ASTM International, or Juvenile Products Manufacturers Association.

    • Infants are placed to sleep on their backs. Side and front sleeping are no longer recommended.
    • No bibs, pacifier clips, hooded shirts, or clothing with drawstrings are on the child.
    • Only one child sleeps in each crib.
    • No mobiles are attached to cribs.
    • Only a tight fitted sheet is used in the crib. There are no toys, bedding, or other items in the crib. This includes crib bumpers, loose sheets, quilts, stuffed animals, etc.
    • Alternatives to blankets are preferred (sleepers, wearable blankets). If blankets are used, they are made of breathable material. The child should be positioned so his or her feet are near the end of the bed, and the blanket should be securely tucked around the bottom and sides of the mattress.
    • The blanket goes no higher than the child’s chest.
    • Blankets are not hung over the sides of cribs.
    • The temperature is kept between 68° and 72° or comfortable for a lightly clothed adult.
    • The sleeping space is not separate from the main infant care area.

    Supervision for Infants

    A trained staff member supervises infants by sight and sound at all times. This means an adult is actively watching and listening for children who are sleeping, falling asleep, and waking. The sleeping space is lit well enough that staff can see each infant’s face and the color of his or her skin. As part of active supervision, staff members regularly make sure sleeping infants’ heads and faces are uncovered. Staff members make sure infants are not too warm or too cool. If a baby is sweaty, a staff member adapts the baby’s attire or the temperature of the room. If a baby’s hands or feet are cold to the touch, a staff member adds an additional layer of clothing (or socks) or adjusts the temperature of the room.

    Safe Sleep Environment for Toddlers and Preschoolers

    Each child in a full-day program should have a cot or mat for rest time. Children should not sleep directly on the floor. Help staff think carefully about cot arrangement. If children are too close together, they may distract each other or spread illnesses. Children’s faces should be at least 3 feet apart or separated by a solid barrier, such as a shelf unit, according to the National Association for the Education of Young Children. Interactions can help soothe children to sleep. Encourage staff to pat children on the back, quietly read a story, or comfort an upset child.

    Adequate Supervision for Toddlers and Preschoolers

    For preschool children, staff-to-child ratios can be doubled during rest time to allow for training or planning within the building. At least one adult must be present in a room of resting children. The other staff members must remain in the facility at all times and be ready to return to the classroom if needed. Maximum group size cannot be exceeded. The adult who stays in the room must also have a fast way to ask other adults for help without leaving the children.

    While children are resting, at least one adult must be actively supervising. This adult can take care of daily tasks like lesson planning, working on portfolios, washing toys, or reading staff-development materials. Activities during rest time must not distract from their primary job of child supervision. Teachers should not conduct personal business during naptime.

    By the age of 5, many children no longer need a daily nap. It is not uncommon in a classroom of 3- to 5-year-olds to have a number of children who do not need a nap. There are several things you can help staff do to accommodate these children:

    Encourage a brief quiet time. Provide cots and a collection of books or quiet toys for the children to play with for a brief period of time.

    Provide supervised play in a different location. Allow non-nappers or early risers to play in a lit room with the supervision of a familiar adult. Be sure to maintain ratio and maximum group size.

    Explore

    Explore

    As a trainer or coach, you are responsible for ensuring that staff keep children safe at all times—even while they sleep. Download and print the Rest Time Scenarios. Read the scenarios. Then write what you would do to support staff in each situation. Share your responses with a colleague and then compare your answers to the suggested responses.

    Apply

    Apply

    Here you will find Safe-Sleep Posters staff can use in infant classrooms. Share with staff or adapt to fit your needs.

    You can also observe in the classroom using the Safe Sleep Best Practices Checklist as a guide

    Demonstrate

    Demonstrate
    Assessment

    Q1

    True or false? Side sleeping is a safe-sleep position.

    Q2

    Tony drops off his 3-month-old son, Rocco. Rocco is asleep in the infant carrier. Tony goes back to the sleeping area and sets Rocco’s carrier (with Rocco inside) in the crib. What should you encourage the staff to do or say?

    Q3

    Which of the following can be placed in a crib with a young infant?

    References & Resources

    American Academy of Pediatrics (2005). 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, 1245-1255.

    American Academy Of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education (2011). Caring for our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 3rd edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Also available at http://nrckids.org.

    American Academy of Pediatrics (2008). Back to Sleep, Tummy to Play. Electronic resource available from www.healthychildcare.org