Implementing the AAP SIDS
Prevention Guidelines During
Discharge Planning In The NICU
Jennifer Sedlmeyer, BSN, RN
Inova Fairfax Hospital Director of Perinatal
Outreach
The Catalyst
• Two years ago, physicians discharging patients
from the Inova Fairfax Hospital For Children
NICU identified that infants in the NICU who
had grown to term corrected gestational age
(CGA) were not following the AAP’s
recommendations for infant sleep.
• At the time of discharge parents were asking
inappropriate questions such as, “Where can I
purchase a gel pillow for my baby to use at home?”
and “How should I prop up the head of the crib at
home?”
The Catalyst
• At the same time, a baby who went
home from the NICU was placed on his
abdomen to sleep and died of SIDS.
• Mom stated “Even though the written
instructions said to place the baby on
his back to sleep, I placed the baby how
the nurses had placed him, on his
tummy”.
Taking Action
• A literature review of the current guidelines
for infant sleep was conducted, focusing on
premature infants nearing term GCA.
• Experts in the field of SIDS were
contacted to discuss the AAP
recommendations and how they pertain to
infants born prematurely.
• The most current recommendations and
research were compiled into a report.
The Task Force
• Staff members volunteered for a SIDS
Prevention Task Force that developed NICU
sleeping guidelines based on the current
recommendations, personal experience,
standards for supporting developmentally
appropriate care, and the opinions of experts in
the field.
• The task force also developed a parent handout
to explain the transition process for preterm
infants as they grow closer and closer to term
CGA.
Results
• Practices in the NICU significantly
improved in safety.
• Surveys of NICU Staff found the
guidelines to be helpful and userfriendly.
• A survey of the NICU Parents showed
an increase in knowledge and in
satisfaction with care.
THE LITERATURE REVIEW
Historical Perspective
• “And this child died in the night;
because she over laid it.” 1Kings 3:19-20
• In 1291 a German poster forbid mothers
from taking their infants under 3 years
of age to bed with them.
• Late 1800’s SIDS was first defined
“Sudden and Unexplained Death in
Children”
Definition of SIDS
• The sudden death of an infant under
1 year of age, which remains
unexplained after
• Thorough case investigation
• Complete autopsy
• Death scene investigation
• Review of the clinical history
Facts About SIDS
• SIDS is the 3rd leading cause of death
in infants under 12 months of age.
• 91% of SIDS deaths occur before 6
months of age.
• The peak is between 2-4 months of age.
• African American infants are nearly 2 ½
times more likely to die of SIDS than
white infants.
Facts About SIDS
• SIDS is not
• Caused by vomiting and choking
• Caused by immunization
• Contagious
• The result of neglect or child abuse
• Hereditary
• Predictable or preventable
Which Babies Are at Greatest
Risk?
• Infants of mothers with late/no
prenatal care
• Infants exposed to nicotine
• Infants with prenatal illicit drug
exposure
• Infants of young mothers (under 20)
Which Babies Are at Greatest
Risk?
• Male infants
• Multiples
• African Americans and Native
Americans
• Infants who sleep in the prone position
• Infants who sleep on soft bedding
• Overheated infants
Which Babies Are at Greatest
Risk?
• Premature infants and/or low
birth weight infants (under 1000
grams)
• A recent study showed that premature
infants were 17 times more likely to die
of SIDS than term infants.
Some Theories…
• Researchers have identified an area
of the brain that is hypoplastic or
absent in SIDS babies
• Medullary arcuate nucleus
This abnormality may put an infant at
risk for sudden death during sleep
• This area of the brain regulates
autonomic and respiratory control
during sleep
•
Some Theories…
• The Atlas-VSC-SIDS Theory
• Suggests misalignment of the spine,
caused by abnormal positioning in utero
or by the birth process, can cause the
cardiovascular and respiratory systems
to malfunction, leading to sudden death
during a vulnerable postnatal period.
Triple Risk Model
Highest risk
for SIDS
1. Critical Stage Of
Development
2. Vulnerable
Infant
Arousal
response deficit or subtle
brainstem dysfunction
SIDS
Highest risk at
2-4 months
3. Exogenous
Stressors
External risk
factors such as
smoking, poor
sleep position,
etc.
The Importance of NICU
Staff in Stopping SIDS
• A recent national study found
that recommendations from the
neonatal nursery staff increased
the likelihood of parents
following through with supine
sleeping and other SIDS
guidelines.
Behaviors That Should Be Taught
To Parents To Reduce the Risk of
SIDS
• Always place your baby on his or her
back to sleep, even for naps.
• Place your baby on a firm mattress in a
safety-approved crib or bassinet.
• Remove soft, fluffy bedding and stuffed
toys from your baby’s sleep area.
• Make sure your baby’s head and face
remain uncovered during sleep.
Behaviors That Should Be Taught
To Parents To Reduce the Risk of
SIDS
• Do not allow smoking around your
baby.
• Do not let your baby get too warm
during sleep.
• Talk to childcare providers,
grandparents, babysitters and all
caregivers about SIDS risk.
Always place your baby on his or
her back to sleep, even for naps.
• The American Academy of Pediatrics
has recommended since 1992 that
infants be placed to sleep on their backs
to reduce the risk of sudden infant
death syndrome (SIDS).
• Infants who sleep on their backs are 3
times less likely to die from SIDS than
those who sleep on their stomachs.
Always place your baby on his or
her back to sleep, even for naps.
• Side sleeping
• While better than prone sleeping, it still has
twice the risk of SIDS as back sleeping.
• Stomach sleeping
• Babies sleeping on their stomachs have lower
blood pressure, higher heart rate and higher
body temperature.
• Arousal may be diminished in the prone position
• These babies are also more likely to overheat &
to rebreathe CO2.
The Back To Sleep Program
• Since 1994, when the Back To Sleep
advisory was first announced, the rate of
SIDS deaths in the U.S. has dropped by
50%.
• When babies all slept on their stomachs,
there were approximately 5000-6000
deaths per year.
• There were just over 2,000 deaths due to
SIDS in 2003.
What About Aspiration?
• According to the AAP “there is NO
evidence of an increase in aspiration or
increased complaints of vomiting since
the incidence of supine sleeping has
increased dramatically” (AAP, 2000).
• There is also some “direct and indirect
evidence that infants who vomit are at
greater risk of choking if they are
sleeping face down” (AAP, 2000).
Place your baby on a firm mattress
in a safety-approved crib or
bassinet
• Never place babies to sleep on a
waterbed, sofa, or cushions.
• A safe crib is in good repair with a
firm mattress and the slats are 2
3/8” apart (close enough so that a
soda pop can cannot fit between
them).
What About Bed Sharing?
• NOT protective against SIDS
• The AAP discourages bed sharing
• Bed sharing does become unsafe and
confers a higher risk of SIDS when…
• Parents smoke and bed share
• Parents are exhausted or under the influence
of alcohol or drugs.
• Encourage rooming in rather than bed
sharing.
Remove soft, fluffy bedding and
stuffed toys from your baby’s sleep
area.
• Eliminate soft bedding such as quilts or
pillows from cribs.
• If using a blanket, use a thin one and tuck it
around the mattress so it reaches only as far
as the baby’s chest.
• Remove bumper pads from cribs.
• Remove wedges from cribs.
• Do not place stuffed animals or toys inside
the sleeping area.
• Make certain crib sheets fit well.
Make sure your baby’s head and face
remain uncovered during sleep.
• Avoid using a blanket or other coverings
over your baby's face as a sun or weather
screen.
• Do not swaddle the baby’s head.
• Consider using a sleep sack
• as an alternative to a blanket.
Do not let your baby get too warm
during sleep.
• Keep the temperature in the baby's room
at a level that feels comfortable.
• Room temperature should be about 70
degrees.
• Dress a baby in as much or as little as an
adult would wear.
• Remember to remove hats and heavy
outerwear when indoors during the cold
weather months.
• Limit layers of clothes and blankets in
warmer weather.
Do not allow smoking around
your baby.
• Nicotine is a neuroteratogen
• Causes cell damage
• May shut off the fetal response to hypoxia
• May disrupt the rhythmic organization of autonomic
function (Zeskind, 2000)
• Babies whose mothers smoke have 3X
the risk of SIDS as babies born to nonsmoking mothers.
• Exposure to other passive smokers
increases the risk in a dose-dependent
manner (Flemming, et. al, 2000).
Talk to childcare providers,
grandparents, babysitters and all
caregivers about SIDS risk.
• About 20% of the babies that die of
SIDS each year die while being cared
for by someone other than their
parents.
• Half of these children die in their first week of day
care.
• Babies unaccustomed to sleeping on
their stomachs are at significantly
increased risk.
• Parents should tell caretakers that they
want the baby to sleep on his/ her back,
even at nap time.
Safe Sleeping
• Ideally this is how an
infant under 1 year of age
should sleep
• He is on a firm, flat mattress in a
crib that meets safety standards.
• There are no quilts, pillows or toys
in the crib.
• The baby is placed with his feet at
the foot of the crib.
• The blanket being used is thin and it
is tucked around the crib mattress,
reaching only as far as the baby's
chest.
Modeling Proper Behaviors In
The NICU
• Research shows that parents model
behaviors seen in the hospital.
• Stomach sleeping in the hospital =
stomach sleeping at home
• Same is true for nesting, bundling with
multiple blankets, stuffed animals in the
bed and placing the head of the bed up
Modeling Proper Behaviors In
The NICU
• In the study that showed premature
infants were 17 times more likely to
die of SIDS than term infants, much
of the risk was attributed to poor
behaviors learned in the nursery.
What do parents see in the NICU?
The head of the bed is up. The baby is
nested with a stuffed animal and quilt in the
bed. She is in the side sleeping position.
The baby is sleeping prone with
multiple layers of soft bedding.
There is a covering over the baby’s
face and there are multiple objects
in the sleeping area.
The baby is nested and is in the side
sleeping position with his face against
the soft bedding.
There is a heavy, non-secured covering over the
baby’s face and the head of the bed is elevated.
This is a baby who never had issues with emesis
or reflux.
This baby’s bedding is covering her
mouth and nares. She had 6 blankets
in the crib.
Learning from Our Mistakes
And Taking Action
What We Learned
• Neonatal hospital staff can
unwittingly be poor role models.
• Prone positioning, elaborate nesting
and the use of soft bedding or gel
pillows may be quite safe within the
confines of the critical care setting
but are potentially lethal at home.
Taking Action…
• Staff members were asked to volunteer for a
SIDS Prevention Task Force.
• The multidisciplinary task force met weekly to
discuss the current recommendations for
preventing SIDS and how we could better
incorporate them in to our NICU.
• The goal of the task force was that all infants
would be following the AAP’s recommendations
for sleep before their date of discharge.
The Guidelines…
The Task Force
• The task force developed these guidelines based
on the current recommendations, personal
experience, standards for supporting
developmentally appropriate care, and the
opinions of experts in the field.
• The task force agreed that guidelines would be
more effective than a policy, recognizing that
there will always be variations from the norm in
our patient population.
• The guidelines are divided into 3 categories: babies less
than 32 weeks CGA and/or <1500 grams, babies between
32 and 35 weeks CGA and/or >1500 grams, and babies
over 35 weeks CGA.
Changing Our Practice
• Sleep position and conditions should be
adjusted to follow the AAP guidelines as
soon as the baby is physiologically and
developmentally ready.
• If a baby is expected to follow any
guidelines for sleeping other than the AAP
SIDS Prevention Recommendations, they
should have specific written instructions
and the physician should discuss the
alternate interventions with the family.
Sharing Our Wisdom
• The task force also developed a parent
handout to explain the transition process for
preterm infants as they grow closer and closer
to term CGA
• If a patient is getting ready to go home and staff
is unable to follow the SIDS prevention guidelines,
an explain of why alternate practices may be
acceptable in the hospital setting but not at home
is given.
• No more waiting until the day of discharge to
review the SIDS Prevention Recommendations!
What We Learned
• There is room for both Developmentally
Supportive Care and SIDS Prevention
Recommendations in the NICU.
• We need to carefully consider each child’s
changing clinical status, gestational maturity
and individual readiness for supine sleeping
with minimal bedding.
• The ultimate goal is to help high-risk babies
become healthy babies
Remember, You Can Make A
Difference!
• Be aware of the risk of SIDS for our
vulnerable patients as they transition
to home.
• Use your influence as healthcare
professionals, through education and
modeling, to minimize the risk!
For More Information
• The National Institute of Child
Health and Human Development
www.nichd.nih.gov, Back to Sleep
• SIDS Mid-Atlantic
703-933-9100
www.sidsma.org
For More Information
• American Academy of Pediatrics
www.aap.org
• Association of SIDS and Infant
Mortality Programs
www.asip1.org
For More Information
• National SIDS Resource Center
www.sidscenter.org
• SIDS Alliance
www.sidsalliance.org
References
American Academy of Pediatrics Task Force on Infant Sleep Position
and Sudden Infant Death Syndrome. (2000). Changing concepts of sudden
infant death syndrome: implications for infant sleeping environment and
sleep position. [on-line]. Pediatrics, 105, (3), 650-656.
Hudson Mohawk SIDS Affiliate. (1998). Reducing the risk of SIDS:
what public health nurses need to know.
Kemp, J. S. & Thach, B. T. (1995). Quantifying the potential of infant
bedding to limit CO2 dispersal and factors affecting rebreathing in
bedding. American Physiological Society, 740-745.
Lockridge, T., Taqino, L. T., Knight, A., (1999). Back to Sleep:Is there
room in that crib for both AAP recommendations and developmentally
supportive care? Neonatal Network, 18 (5), 29-31.
References
Moon, R., (2000). Answering medical questions about SIDS.
Presented at the National SIDS Alliance Conference, Salt Lake City, Utah.
Willinger, M., Ko, C. W., Hoffman, H. J., Kessler, R. C., Corwin, M. J.
(2000) Factors Associated with caregivers’ choice of infant sleep position,
1994-1998. JAMA, 283 (16), 2135-2142.
Zeskind, P. S., (2000). Maternal cigarette-use during pregnancy
disrupts rhythmic activity in fetal autonomic regulation. Presented at the
National SIDS Alliance Conference, Salt Lake City, Utah