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Safe Sleep
Objectives
• Increase understanding of sleep-related deaths • Describe the Triple Risk Model
• Identify modifiable/non-modifiable risks
• Understand meaning of “Alone, Back, Crib”
• Motivate integration of Safe Sleep into nursing practice
SIDS Sudden Infant Death Syndrome
SUID Sudden Unexpected Infant Death
ASSB Accidental suffocation and strangulation in bed
All are terms to describe
sleep-related deaths
of a baby younger than 1 yr of age
Chances of these happening go down with a few simple changes in how babies sleep
1983-1992 5,000-6,000 SIDS deaths/yr
1992 American Academy of Pediatrics recommended infants <1 yr be placed to sleep on back or side
1996 Recommendation changed to sleep only on back
Since babies have been put to sleep on their backs
SIDS deaths have ’d by 50%
However
putting babies on their backs has not been enough to prevent sleep-related deaths
There are other risks Some are modifiable
Some are non-modifiable
#1 #2
#3
#1 Vulnerable Infant
Some babies are more likely to die from SIDS because of abnormal control of: - Blood pressure - Heart rate - Respiration - Chemoreception - Upper airway reflexes - Thermoregulation Non-modifiable Risk Factor
#1 Vulnerable Infant
Prematurity and Low birth weight
SIDS risk: with birth wt and gestational age
Non-modifiable Risk Factors
#1 Vulnerable Infant
American Indian infants >3x more SIDS than Caucasian infants
African American infants >2x more SIDS than Caucasian infants
Non-modifiable Risk Factor
Race
#2 Critical Developmental Period
Rapid growth and development of brain in 1st year of life
Autonomic function reorganization Learned protective behaviors
Non-modifiable Risk Factor
#3 External Stressor/s
We can’t control whether a baby is a “vulnerable infant” or whether a baby is in a “critical developmental period”
However
We CAN control external stressors ALL are modifiable
#3 External Stressor/s
Second-hand Smoke
#3 External Stressor/s
Follow ABC’s of Safe Sleep
Alone
Back
Crib
Alone
The competition we’re up against
This is what we’re asking parents to do
NO
Pillows
Loose blankets
Stuffed toys
Bumper pads
This is no longer acceptable
A blanket can become a suffocation hazard If you need to use a blanket use it “Feet to Foot”
Like this Not this
Yes! to Blanket Sleepers
After 37 weeks and prior to discharge swaddling with a blanket during sleep is not recommended
34-37 weeks gestation: - Swaddle with one blanket below the arms - If second blanket is needed for thermal support, place it no higher than baby’s chest and tuck it around crib mattress
Swaddling
What about the baby with poor upper body tone?
May need to be swaddled from mid-arms down to help bring arms to midline
Good Rules of Thumb
Room temperatureshould be comfortable for a lightly clothed adult ~ 72 degrees
Dress baby in no more than one layer than you are dressed
A well-fitting hat is OK for
thermoregulation for preterms
Not thisThis
Remove for sleep at 37 wks or prior to discharge
This might look cozy
But it is DANGEROUS!
Danger of entrapment and suffocation
Extremely high risk of death on couches and armchairs
Parents should not feed their baby on a couch or armchair if there is a chance of falling asleep
Baby should sleep alone
Baby may be in parent’s bed for feeding or comforting but should be returned to his/her own bed when parent is ready to return to sleep
Billboards in Milwaukee, WI
“Your baby sleeping with you can be just as dangerous”
Alone but IN room with mother is best
Back
Every baby should be placed “back to sleep” Every sleep by Every caregiver for the 1st year of life
But babies sleep better on their stomachs!
Yes, they do
But that is why they are more likely to die!
Prone position can result in:
’d re-breathing of carbon dioxide
’d stimulation of laryngeal receptors causing apnea
’d efficient loss of heat
’d arousal
What about spitting up?
*Less likely to choke in supine position*
In prone position milk may pool in the hypopharynx
Guidelines for premature infants born at < 34 weeks who are medically stable
By 32-34 weeks gestation:Begin transition to supine sleeping in a flat bed without nests, pillows or developmentalsupports
By 34 weeks gestation or when successfully weaned to an open crib:
Infant should sleep supine, without nests or developmental supports and with head of bed flat
What about a baby with reflux?
head of bed does NOT reflux head of bed may result in baby sliding and compromising airway
However:- Do feed in an position- Do hold in position or keep head of bed for 30 min after feeds
Exceptions to this?
• Babies with life-threatening airway issues (e.g. laryngeal cleft…)
• Babies with impaired airway protective mechanisms (e.g. paralyzed vocal cord…)
• Babies with aspiration related to reflux
• Babies awaiting anti-reflux surgery
What about positioning devices?
None have been approved
But what about positioning devices for our < 32 wk preemies and sick babies?
Yes! We can use them!
Safe Sleep guidelines are for medically stable babies
What about delayed upper body development?
Tummy Time when awake and alert
Upper body strength will be met with a total Tummy Time of at least 1hr/day
What about flat spots on a baby’s head?
• Tummy Time helps to reduce flat spots
• Changing the direction a baby sleeps in reduces flat spots
Flat spots usually resolve in a few months after a baby learns to sit up
What about a bald spot?
Consider a bald spot on the back of a baby’s head a sign of a healthy baby!
Once an infant can roll from supine to prone and from prone to supine, infant can be allowed to remain in the sleep position that he or she assumes
Crib
Crib Pac and Play
Firm mattress covered by a fitted sheet
What about swings, bouncy seats…?
Should not be used for sleeping
If an infant falls asleep in one, he or she should be removed and placed in their bed soon as it is practical
Exceptions to Safe Sleep:
** Must have a physician or NNP order documenting exception and indication for exception
Example: may have head of bed up 30◦- infant with aspiration noted on milk scan
Example: may sleep in swing - infant with Neonatal Abstinence Syndrome (NAS)
Prior to discharge:
- Attempt should be made to assess infant’s ability to eliminate exception(s) and follow all Safe Sleep environment recommendations
- If infant continues to need any exception(s) to Safe Sleep recommendations these should be fully discussed and planned for at time of discharge
Are there other things that might protect babies from sleep-related death?
Protective effect of a dry pacifier
This Not this
Not these either
Some guidelines for pacifiers:
- Offer pacifier, but don’t force it
- If pacifier falls out while baby is asleep do not replace it
- Wait until breastfeeding is well established before offering pacifier
Two more things that protect babies from SIDS
Breastfeeding Immunizations
Some babies who died of SIDS had recent infections before they died
Breastfed babies have fewer infections
Immunizations cut a baby’s risk of SIDS almost in half
Immunizations
So what can we do?
Safe Sleep needs to start with us!
We need to teach parents Safe Sleep
We need to model Safe Sleep
Transition process in the NICU
Prone Supine
Supported Unsupported Positioning
“ILL” status “HEALTHY” status
Summary
• Triple Risk Model- Vulnerable infant- Critical Developmental Period- Outside stressor/s
• Alone, Back, Crib
• Use of dry pacifier, breastfeeding, immunizations
• Role modeling for families
Safe Sleep
Safe Sleep
STANDARD OF CARE
References
American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics. 2000;105:650–656http://pediatrics.aappublications.org/content/105/3/650.full.html
References
Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, DHHS. (2007).Curriculum for Nurses: Continuing Education Program on SIDS Risk Reduction (06-6005).Washington, DC: U.S. Government Printing Officehttp://www.nichd.nih.gov/publications/pubs_details.cfm?from=&pubs_id=5685
References
Filiano, JJ, Kinney, HC. A perspective on neuropathologic findings in victims of the sudden infant death syndrome: the triple risk model. Biolol Neonate. 1994;65(3-4):194-197.
Ibarra, B. Family Teaching Toolbox: A Parent’s Guide To A Safe Sleep Environment. Advances in Neonatal Care. 2011; 11 (1), p 27-28
References
Moon, RY, Fu, L. (2012). Sudden infant death syndrome: an update. Pediatrics in Review. DOI: 10.1542/pir.33-7-314
Task Force on Sudden Infant Death Syndrome. SIDS and other sleep- related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2001;128 (5) e1341-e1367.http://pediatrics.aappublications.org/content/128/5/e1341.full