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Safe Sleep Guidelines

The Safe Sleep Guidelines this following advice is guided by are by the American Academy of Paediatrics who are the global leader in Sleep Research and they update their research every 3 to 5 years or as necessary.  The guidelines are for infants from Newborn to 1 year old.

With SIDS (Sudden Infant Death Syndrome) a baby that appears healthy dies suddenly in their sleep and the death cannot be explained.  There is nothing that can prevent this.  But there are other causes of infant death from accidental suffocation in their sleep which can be prevented by ensuring their sleep space is as safe as possible.

Safe Sleep is important in order to keep our babies safe.  It’s as simple as that.

Safe Sleep Summary?

The below infographics summarise the main guidelines on Safe Sleeping and Safe Places to Sleep then will go into a lot more detail referring to the guidelines of the AAP.

What Are the Safe Sleep Guidelines?

The following breaks down each of the Safe Sleep Guidelines in more detail:

1) Baby Should Sleep On Their Back

Baby should be placed on their back to sleep on a flat surface (not inclined) for every sleep until 1 year of age. This includes for babies with Gastrointestinal Reflux or receiving Nasogastric or Orogastric feeds.  If the sleeping surface is inclined (raised up) it can risk the infant sliding into a position that may compromise their breathing.  When an infant reaches the age they can roll from their back to front and front to back (approx 3 months) then they can remain in this position but they still should be placed on their back to sleep until 1 years old.

2) Firm Mattress

Your baby should sleep on a firm flat sleep surface mattress in a cot, bassinet or playyard that meets the safety standards of the country in which you live conforming to the Consumer Product Safety Commission (CPSC) – their website is www.cpsc.gov

  • A fitted mattress protector or fitted sheet is acceptable but should be tightly fitting and thin
  • Sleep surface should be flat – inclines of the mattress at one end by placing wedges or pillows etc underneath have been shown to be unsafe for infant sleep including with infants with Gastrointestinal Reflux
  • Sleep surface should not change its shape when the fitted sheet for that model used and does not indent or conform to the shape of the infants head when their head is placed on the surface
  • Only use mattresses designed for the specific product
  • Pillows or cushions as mattress substitutes or in addition to a mattress or not appropriate for use with infants under a 1 year old
  • If buying a used product check that it has not been recalled by the CPSC (see their website www.cpsc.gov) and ensure there are no missing parts, instructions or the sellers have attempted to fix broken components
  • Regarding Cradle boards it should be ensured that infants do not overhead due to overbundling in the cradleboard

3) Keep Soft Objects Out of the Sleep Place

Apart from the fitted sheet and fitted mattress protector airway obstruction from soft objects or loose bedding is the most common reason for accidental suffocation of an infant – to make it simple your baby should be in clothes alone or with a swaddle (early weeks) or sleep sack in their crib, bassinet or playyard  – there should be not any additional items such as:

  • Blankets, muslins, towels, rugs, sheepskin rugs, or other non fitted sheets and covers
  • Weighted blankets and weighted objects should not be placed near or on your baby
  • Soft toys, pillow like toys
  • Bolsters, padding and bump cushions
  • Crib tents or cot tents
  • Positioners

With current safety standards for crib slats any bumper pads or similar products are not necessary for safety against worries like head entrapment or injury.

4) Avoid Any Surrounding Hazards

Make sure the sleep space is not near anything like dangling cords, loose covers, curtains that the baby can pull into their crib, bassinet or play yard.

5) Baby Should Sleep Separately in Caregivers Room

It is recommended your baby sleeps in the room of the person looking after them for at least the first 6 months.  There is evidence that this reduces the risk of Suffocation, strangulation and entrapment that may occur as much as 50%.   Note this means sharing a room not your bed.  They should be sleeping separate to your bed in a bassinet or crib.  There is no specific evidence on when it might be safe to move them to a separate room after 6 months.

  • Placing crib or bassinet close to your bed so your baby is in within arms reach can help with feeding, comforting and monitoring them
  • If your baby is brought into your bed for feeding or comforting they should be returned to their crib or bassinet when you are ready to return to sleep – ensure your sleep surface is also firm and there are no sheets, blankets or soft toys around you in the case of you falling asleep unintentionally while comforting or feeding in your bed – make sure to return your baby to their separate sleep surface as soon as you awaken
  • Couches and armchairs are extremely dangerous places for infant sleep with placing them at 22-67 x increased risk of suffocation by entrapment, wedging between cushions or the person laying onto the baby

6) Extra Care if Bed Sharing Chosen

The AAP understand and respect that parents may routinely choose to co sleep with their baby for reasons such as facilitation of breastfeeding, cultural preferences and personal beliefs it is better and safer for their baby.  However on basis of evidence AAP is not able to recommend bed sharing under any circumstances.  However if you wish to continue with Co-Sleeping ensure the following:

  • Your bed surface is firm and not soft such as waterbed, old mattress, couch, sofa or armchair
  • Their are no loose bed clothing or blankets, comforters or soft toys around you and your baby
  • You are not impaired in your alertness or ability to arouse because of fatigue, use of sedating medications (antipressants, pain meds) or substances such as alcohol and illicit drugs
  • The bedsharing is not with a current smoker including if smoked during Pregnancy
  • Note bed sharing with anyone other than the babys parent increases the risk of bed sharing by 5-10 times

7) Avoid Overheating and Head Covering

Although studies have shown increased risk of SIDS with overheating although there is no evidence to provide a specific room temperature guidelines so the following advice can be used:

  • In general dress your baby appropriately for their environment with no more than 1 layer more than you would wear to be comfortable in that environment – make sure it is fitted clothes or jumpsuit, swaddle (early weeks) or sleep sack – not loose clothing
  • Check your baby for signs of overheating such as sweating, skin looking flushed or their chest feeling hot to touch
  • Avoid overbundling and covering the face or head – it is advised not to place hats on infants indoors
  • Fans so far do not have sufficient evidence to suggest being used as a SIDS reducing strategy

8) Swaddling

There is no evidence to support Swaddling reducing the risk of SIDS.  Swaddling is often used to calm babies, giving an almost cocoon like effect and encouraging them in a supine position but should only be used in the early weeks.  Once they start to show evidence of rolling (around 3-4 months – can be earlier) the swaddling high risk for SIDS if they roll onto their front.

  • Only use for the early weeks – until they start showing signs of rolling (can be anytime from 8 weeks old)
  • Ensure any Swaddles or Sleep Sack Swaddles that enclose the arms are no longer used when show any early signs of rolling – Once starting to show rolling you can change to Sleep Sack Swaddles that expose the arms

9) Be Wary of Using Commercial Devices

Be wary of commercial devices that claim to reduce the risk of SIDS or other sleep-related deaths.  There is no evidence that any of these devices reduce the risk of these deaths and may provide a false sense of security and complacency for caregivers.  If using one of these devices it is still important to follow the guidelines on Safe Sleep practices outline by the AAP.  Information about a specific product can be found on the CPSP Website site – www.cpsc.gov.

10) Avoid Cardiorespiratory Monitors as Strategy to Reduce Risk

The use of Cardiorespiratory monitors has not be documented to reduce the risk of SIDS.   Again these monitors can lead to parent complacency and not following in line with the Safe Sleep Guidelines.

These monitors have their use when prescribed to help with infants who have suspected apnea, bradycardia and decreases in oxyhaemoglobin saturation by a Medical Provider.

11) Avoid Smoking, Alcohol & Narcotics

Smoking, alcohol and drug use during Pregnancy and in the infants environment are all major risk factors for SIDS.

  • It is advised that no one smoke near to an infant.
  • It is advised that non one vapes or uses an electronic cigarette near to an infant – they still contain nicotine which has been linked to sleep related infant deaths.
  • Caregiver alcohol, marijuana, opioid or illicit drug used in combination with bed sharing puts the infant at particularly high risk of SIDS and suffocation

12) Pacifier Use

Offering a pacifier when your baby naps and bedtime is recommended to reduce the risk of SIDS.  However if breastfeeding your baby this pacifier introduction needs to be delayed until breastfeeding is firmly established which means having sufficient milk supply, consistent, comfortable and effective latch for milk transfer and their weight gain is sufficient compared with normal growth curves.

Babies who are not being breastfed can use a pacifier as soon as desired:

  • Offer the pacifier when placing them down for a sleep – do not force to take if they refuse it
  • The pacifier does not need to be reinserted once the infant has fallen asleep
  • Never hang a pacifier around their neck or attached to their clothing when placing to sleep due to risk of strangulation
  • Never attach objects such as blankets, soft toys are other items to the pacifier which may pose a suffocation or choking risk

13) Preventing Flat Head (Plagiocephaly)

When babies are lying flat for long periods of time they can develop a flattened area on the side of the head called Plagiocephaly.   Supervised tummy time is recommended soon after leaving hospital to help prevent this from developing and also encourage infant development.   Place your baby on their tummy with head turned to one side for a few minutes to start with alternating sides the head is turned each time you practice.  Then increase gradually aiming for at least 15-30 minutes daily by 7 weeks of age.   You may find they cry or become agitated when first trying tummy time but this will go in time as they become used to the position.

Moon R, Carlin R & Hand I (2022) Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment.  From the American Academy of Paediatrics.  Policy Statement. https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022

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