Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I’m Dr. Rachel Moon, and I am a Professor of Pediatrics at the University of Virginia School of Medicine. Today we’re going to talk about what you need to know before you talk to a family about what safe sleep looks like for their infant. We’re going to talk about the importance of safe sleep habits, the AAP safe sleep recommendations, guidelines for infant sleep products, and tummy time.
Why do we talk about safe sleep for infants?
Following safe sleep guidelines is the best way to protect a baby from dying suddenly and unexpectedly from sudden infant death syndrome (SIDS), accidental suffocation or strangulation, and deaths with unknown case. All of these deaths are sometimes referred to as sudden unexpected infant death (SUID) or sleep-related deaths.
What causes these deaths?
It is believed that some infants have some intrinsic vulnerability that results in impaired arousal – meaning that these babies have difficulty arousing – or waking up – when they encounter a situation in which they are becoming hypoxic or low in oxygen or hypercarbic or high in carbon dioxide. We cannot reliably identify which babies will have this difficulty and vulnerability but know that when they are at a certain age – somewhere between 1 and 6 months being the age of highest risk – and they are in an unsafe sleep environment, an infant can die suddenly and unexpectedly. Since we can’t identify who these infants are, we focus on the sleep environment as the best way to protect these infants from dying. It is important to note that there are socioeconomic and racial/ethnic disparities in sleep-related deaths. In the US, rates of sleep-related deaths for non-Hispanic black and American Indian/Alaska Native infants are 2-3 times higher than infants of other race/ethnicities. In general, having fewer resources is also associated with having higher rates of sleep-related deaths.
Let’s talk about the safe sleep recommendations. The easiest way to think about the recommendations is that they accomplish 2 basic goals. The first goal is to increase a baby’s arousability. Believe it or not, if an infant has frequent awakenings through the night, that is protective for the infant. Because of this, in general, if something makes an infant sleep longer or not wake as easily, it is probably not recommended from the safe sleep standpoint. The second goal is to keep the infant out of a sleep environment in which they could develop asphyxia, meaning not enough oxygen. While we’ll talk about each of the recommendations in detail, behaviors that improve the infant’s arousability include sleeping on the back, breastfeeding, pacifier use, and when the infant and parent sleep in the same room. Examples of behaviors that decrease arousability include sleeping on the side or stomach, smoke exposure, both prenatal and environmental after birth. Factors that create potentially asphyxiating environments include soft sleeping surface, soft bedding, covering the face during sleep, and sleeping on the side or stomach.
We ask about where and how the infant is sleeping at every well child visit until the 1 year of age and give guidance about safe sleep. It is also important, no matter where you are in the hospital, for all staff to model safe sleep for infants. When asking and talking about sleep practices, be open and nonjudgmental in your questions and discussions. An example of ann opening question might be something like: “Where are you planning on having your baby sleep at home?” or “Where does your baby sleep at home?” Many families have very strong cultural or societal reasons for where and how their babies sleep the way they do. Talking about safe sleep as a part of other safety messaging, such as talking about the risk of falls and potential skull fractures if infants fall from an adult’s arms or a sleep surface, can be helpful. Some families do not have the financial resources to follow safe sleep guidelines – for instance, they may have a job that keeps them from being able to breastfeed their infant, or they may not be able to afford a crib. You may be able to recommend a flat firm surface that is less expensive than a standard crib, for example, a play yard. Check with your resident, attending, and/or social worker to see if there are options to get a free crib or play yard for families with financial constraints.
You may hear people talk about the “ABC’s of safe sleep”: A stands for alone, meaning that nobody and nothing should be in the sleep space with the infant; B stands for baby sleeping on the back, and C means in a crib, bassinet, or play yard that meets federal safety standards. This can be an easy way to remember the basics of the safe sleep recommendations.
But let’s talk about the recommendations in a little more detail. These should be practiced for all sleep – so nighttime when parents are asleep, and naptime, even when parents are awake.
1. Back to sleep for every sleep. Infants should be supine – or on their backs – for naps and night time sleep. Preterm infants, by the time that they leave the hospital, should all be sleeping on their backs. Some parents want to place their infants on the side or prone – meaning on their stomachs – because they’re worried that the infant may spit up and then choke on or aspirate on the spit up. It’s important that parents know that the back position does not increase the risk of choking or aspiration. In fact, if you remember back to your anatomy, when the infant is on the back, the trachea is superior to the esophagus, so any spit up has to go up against gravity to go into the trachea and become aspirated. If you’re having trouble visualizing this, there’s a great visual aid of this on the NIH safe to sleep website, and I’ve put that link in the show notes. Even infants who have gastroesophageal reflux should be placed on their backs when they’re sleeping. Parents may ask what they should do once the infant starts to roll from the supine position to the prone position. They should be placed on the back for sleep. If the baby can roll to their belly and then back again, then it’s fine to not move the infant. However, it’s important to remind parents that, if their infant is rolling, they need to be doubly sure that there are no blankets, pillows or anything that the infant can roll into in the infant’s sleep space.
2. The infant should sleep on a firm, flat, noninclined sleep surface. The best place is a crib, bassinet, or play yard that meets federal safety standards. There should be a tightly fitting sheet and nothing else in the crib or bassinet. The sleep surface should ideally be flat – meaning horizontal, and definitely not more than a 10 degree incline, because when infants are at an incline, they have a hard time keeping their head up and their airway straight. This creates muscle fatigue for the baby. Firm means hard. The surface should be hard enough that it maintains its shape and doesn’t indent when the infant is placed on the surface. Just so you know - There are no safety standards for adult beds, and many of them are much too soft for infants. Additionally, infants can become trapped between the adult bed and the headboard, footboard, or wall. If you are working with families from American Indian or Alaska Native communities, you may see infants who sleep on traditional cradleboards, and these are considered to be culturally appropriate sleep surfaces for the infant.
3. If an infant falls asleep in a car seat, swing, or other product that is at an incline, it is recommended that the infant be moved to a firm, flat surface as soon as it is practical. If the family is travelling, the car seat is absolutely the safest place for the infant to be. But when the family gets to their destination, the infant should be moved to a firm, flat surface. Some pediatricians will also recommend that, if possible, an adult sit in the backseat next to the infant.
4. There should be no bedding, such as pillows, blankets, bumper pads, stuffed toys, or fur-like materials in the infant’s sleep area. You may see some interesting products, such as stuffed animals attached to pacifiers. None of these should be in the infant’s sleep area, because any of these products can obstruct an infant’s nose and mouth. We also don’t recommend any weighted blankets or swaddles on or near the infant. If parents are worried that the infant will get cold, then they can either dress the infant in layers or use wearable blankets, which are sometimes called sleep sacks. This keeps the infant warm without the risk of covering the head or face.
5. The infant should be breastfed as much and for as long as possible. Breastfeeding for at least 2 months is associated with a 50% reduction in SIDS risk, and this protection increases with longer duration and with exclusive breastfeeding, but any breastfeeding is better than none.
6. The infant should sleep in the parents’ room, close to the parent’s bed but on a separate surface designed for infants, ideally for at least the first 6 months of life. Studies have shown that this arrangement decreases the infant’s risk of SIDS by up to 50%. I recommend that the parents put the crib or bassinet right next to the side of their bed. That makes it easier for them to check on the infant and to feed the infant.
7. Couches, sofas, and padded armchairs are probably the most dangerous places for infants to sleep. Infant should never sleep on these surfaces, with or without another person.
8. We don’t recommend that infants sleep in the bed all night long with their parents, because of the increased risk of suffocation or SIDS. However, the adult bed is safer than a couch, sofa, or armchair, so when parents feed their infant in the middle of the night, and they’re at risk of falling asleep, they should do so in the adult bed. If they fall asleep while feeding, they should just move the infant back into the crib or bassinet when they wake up. If a parent anticipates that they might fall asleep while feeding, we also recommend that the parent proactively remove all of the blankets and pillows out of the bed beforehand.
9. There are certain circumstances when bed sharing is particularly dangerous. This includes when the parent is taking any medication, alcohol, or any illicit drugs that makes it more difficult for the parent to be aware of what is going on or to wake up. Bed sharing with an adult who smokes, even if they are not smoking in the bed, or bedsharing when the infant was exposed to smoking in utero is dangerous, because the smoke exposure blunts the infant’s ability to arouse. Bed sharing is also more dangerous for infants younger than 4 months of age, infants who are born preterm or with low birth weight, or when bed sharing occurs with a non-parent or with blankets, pillows, or other soft bedding.
10. Offering a pacifier at sleep time has been associated with a decreased risk of SIDS. We’re not sure why this is the case, but the decreased risk has been shown in multiple studies, and the strange thing is that the infant just has to have the pacifier in their mouth as they are falling asleep. It’s protective even if it falls out after the infant is asleep. If the infant is being breastfed, then wait until the mother is confident in good latching technique and breastfeeding is well established with milk supply and weight gain before you introduce the pacifier. If the infant doesn’t want the pacifier, don’t force it. We don’t recommend pacifiers that have stuffed animals, blankets, or long cords attached to them.
11. Because smoke and nicotine exposure are major risk factors for SIDS, we recommend that parents stay smoke-free during pregnancy and after the infant is born. If the pregnant parents smokes 1 cigarette per day during pregnancy, that doubles the infant’s risk for SIDS, and the risk increases with each additional cigarette that is smoked. There are multiple reasons why smoke and nicotine exposure are problematic, but one of the main reasons is the negative effect on the infant’s ability to arouse.
12. Similarly, parents should avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth, as there is an increased risk of SIDS with prenatal and postnatal exposure to these substances. As we already mentioned, Parental alcohol, marijuana, opioid, and/or illicit drug use in combination with bed sharing places the infant at particularly high risk for SIDS and suffocation.
13. Infants should be fully immunized. There is no evidence that there is a causal relationship between immunizations and SIDS. Instead, vaccination may have a protective effect against SIDS.
I want to talk a little bit about sleep products – meaning commercial products that are used with sleeping infants. This can include wedges to prop babies in a certain position, padded loungers or pillows to rest babies on, and smart cribs. If you do a search on any online search engine at any website that sells infant products – or look on any social media platform, you will see many sleep products. If a parent asks you about any product, look at it carefully. The general rule of thumb is that if a product is inconsistent with safe sleep guidelines, health care providers should not recommend it. For example, if the surfaces are not firm and flat, or if the sides are padded such that the infant’s nose and mouth, if pressed up against the side, would become obstructed, then the product should not be used for sleep. You should be suspicious of products that claim to reduce the risk of sleep-related deaths, because there is no evidence that this is true for any product. We also worry that if a parent thinks that any product keeps the infant safe, they will become more complacent about following other safe sleep recommendations. This is also true for home cardiorespiratory and pulse oximetry monitors. They don’t reduce the risk of SIDS or sleep-related deaths. While there is no problem with parents using monitors, they are not a substitute for following safe sleep guidelines.
Lastly, I want to talk about tummy time. Babies should spend time on their tummies when they are awake and supervised. Infants who sleep supine may naturally spend most of their awake time on their backs as well. This increases the risk of asymmetric head molding, also called positional plagiocephaly. Additionally, studies found that supine sleepers achieve motor milestones that require use of the upper body, such as rolling, at a later age. Tummy time helps with infant development, and helps decrease positional plagiocephaly. Parents can start putting their infant in tummy time as soon as they come home from the hospital after birth for a few minutes at a time. They should work up to at least 15-30 minutes total each day by the time the infant is 7 weeks old.
Even if you do not become a pediatrician, you will have family members and friends asking you about safe sleep. So feeling comfortable with talking about safe sleep is important.
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