Safe to Sleep: An Update

Nearly twenty years ago, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) launched the “Back to Sleep” campaign that sought to educate parents and caregivers about putting their babies to sleep on their backs.

Research had shown that back sleeping significantly lowers the risk of Sudden Infant Death Syndrome (SIDS).

While healthcare providers have long since embraced back sleeping as best practice, they haven’t been as welcoming to some of the newer updated safe infant sleeping recommendations endorsed by the NIH/NICHD, according to Sharon C. Hitchcock, MSN, RNC, maternal-newborn educator and adjunct faculty at the University of Arizona College of Nursing.

The NIH/NICHD’s expanded campaign, now known as the Safe to Sleep campaign, endorses the American Academy of Pediatrics’ (AAP) updated recommendations that address much more than behaviors to reduce SIDS.


Apply to Any Healthcare Job in Seconds

No other resource can speed up your job search like the ADVANCE job board. On our site, you can save openings and submit applications in just a few quick clicks. You can even track your status up to the minute with your own personalized dashboard. Energize your job search >>

“Back to Sleep was mainly to promote behaviors to reduce SIDS, and Safe to Sleep is now more of a comprehensive campaign to promote a safe sleep environment,” said Shavon Artis, DrPH, MPH, the Safe to Sleep program coordinator. “So back sleeping is still important, but now it is about promoting back sleeping along with other safe sleep environment factors for infants.”

“The AAP’s new list of recommendations greatly expands the original focus on back-only sleep and now focuses on the whole sleep environment.” Hitchcock added. “They now have a total of 18 recommendations, and not all of them are geared toward parents – some are geared towards the media, manufacturers and healthcare providers.”

Now the recommendations include a direct appeal to nurses and other healthcare providers to “endorse the SIDS risk-reduction recommendations from birth,” as stated by the AAP’s policy statement. And according to Hitchcock, this could mean some big changes for nurses used to doing things the old way.


One of the reasons the AAP included recommendations asking for support from the healthcare community is because they know following these steps can significantly reduce sudden unexpected infant deaths (SUIDs) – an umbrella term that encompasses both SIDs and other sleep-related infant deaths.

Many of the SUID or other sleep-related deaths are due to suffocation and are preventable, according to Hitchcock.

“The AAP has said, ‘we need hospital nurses and childcare providers to endorse these recommendations. We need you guys to model and teach it, and we need you to be persuasive, because of the barriers,'” Hitchcock explained. “This is one of those topics parents don’t just love. And most of the barriers are related to the most important recommendations or what we like to call the ‘ABCs of Safe Sleep.”

The ‘ABCs of Safe Infant Sleep’ stand for: A, alone; B, on their back; and C, in an empty crib.

Other recommendations include: a ?rm sleep surface; room sharing without bed sharing; prenatal care; avoiding smoke exposure; breastfeeding; a paci?er at nap time and bedtime; and avoiding overheating. The recommendations with the most barriers, according to Hitchcock, are bed sharing, back-sleeping, and an empty crib.


“It’s a challenge for some parents and caregivers to follow the recommendation against bed sharing,” Artis said. “We know that some families do practice bed sharing, but we also know that having an infant sleep in an adult bed puts them at greater risk of dying from SIDS or accidental suffocation.”

“Many babies die while bed sharing. But some babies sleep better with a parent, breastfeeding is easier, and there is bonding that takes place – so parents may hear conflicting recommendations,” Hitchcock added.

“Breastfeeding moms often fall asleep with their babies, and often ask, ‘then how can I breastfeed?’ You can by room sharing instead. Have the baby in the same room with you, in a separate sleep space, ideally within arm’s length. Studies have shown death rates are lower when babies are in the same room with parents. The risk of bed sharing is just not worth it.”

When it comes to the other recommendations parents resist, Hitchcock noted many parents (upwards of 25%) still place their baby on their stomach or side and allow loose or fluffy items in the crib such as blankets, stuffed animals or bumper pads. These skeptical parents are going to look to someone they trust for information such as this, and according to Hitchcock and Artis, that’s usually going to be the baby’s very first nurse.


In order for nurses to have the right information to share with their new parents, Artis strongly urged facilities to provide training sessions for staff and set standards of care for their clinical settings. The NIH/NICHD provides education materials as well as a continuing education program on SIDS risk reduction geared toward nurses.


Stroke & Sleep Apnea

Nurses need to be aware that sleep apnea after stroke increases the risk of recurrent ischemic attack.

“All nurses who work in that setting should place a baby on his or her back to sleep every time, making sure there is nothing else in crib or baby’s sleep area,” Artis stressed.

But Hitchcock admitted that not all nurses are on board yet, and some parents are still getting mixed messages. She cited a lack of understanding as the underlying cause of inconsistent practices among nurses. When training at her facility, Hitchcock realized nurses simply need to see the evidence and they are quick to get on board with the new safe sleeping practices.

“The research is compelling: The recommendations are based on strong and consistent evidence and have been considered best practice in the medical community for many years,” Hitchcock explained. “I am convinced that if we can get nurses on board, and not just perinatal nurses, but all nurses, we will prevent many needless deaths.”


Children & Depression

Learn about choice theory psychology in the treatment of children with depression..

The most important factor of the new Safe to Sleep campaign, according to Hitchcock and Artis, is starting parent education from day one – and that’s why nurses are the perfect safe infant sleep champions. When asked why nurses were so vital to the success of the updated campaign, Artis didn’t hesitate to give nurses the praise they deserve.

“Research shows us that nurses are actually one of the most trusted healthcare providers, and they are oftentimes the healthcare provider that parents model behavior after both in the hospital and when they take their babies home,” Artis explained. “So nurses are a good model for demonstrating safe infant sleep behaviors for parents and families. Nurses are the individuals they observe first when they take their babies home on how they should put their baby to sleep.”

“Since almost every baby is born in a hospital, these nurses have a critical role in teaching mothers safe infant sleep,” Hitchcock added. “We need to convince nurses that most SUIDs can be prevented and that they have an active role in educating parents from the moment of birth – and it’s not just educating, but modeling safe sleep.”

“We will never prevent all SIDS cases, just like we wouldn’t eliminate lung cancer if we eliminated smoking,” Hitchcock concluded. “But, in one recent study, more than 90% of infant sleep-related deaths occurred in unsafe sleep environments. If we could prevent these deaths, we will have made great progress.”

Rebecca Hepp is on staff at ADVANCE. Contact: [email protected].

About The Author