Safer Sleep for Babies: guide for professionals

Safer sleep for babies

Although sudden infant death syndrome (SIDS) is now very rare, over 200 babies still die every year. Yet we now have accurate information about how and where babies die and research that tells us how to prevent them dying. The organisations listed in this guide have come together to improve messages and take new action to tackle this. Your role is crucial - by talking to families, and supporting them with understanding how to avoid the specific risks for their baby, we can help to reduce the number of babies dying.

Where the term parent is used, this includes anyone involved in the care of a baby.

Key messages

The number of babies who die of SIDS could be reduced dramatically if families followed three key pieces of advice:

• Put them on their back for every sleep
• In a clear, flat, separate sleep space
• Keep them smoke-free day and night
• Babies need a sober carer to respond to their needs

Back to sleep: the simplest message

The big drop in the number of SIDS deaths has been largely attributed to the success of the message to sleep babies on their back - never their front or their side.

Despite this clear message being in place for many years, around 10% of families still do not adhere to the message, and sleep their baby in another position.

We need to make sure families know the significant risk:

Back to sleep, for every sleep

Back sleeping needs to be consistent from day one. The odd night that a baby is slept differently, for whatever reason, is the one where the risk of SIDS peaks. Premature babies may have been slept differently whilst on a neonatal unit for health reasons, but when they go home they should be slept on their backs unless there is different medical advice.

Side sleeping is not safe

A baby sleeping on their side is not in a stable position, and should never be propped to stay in this position.

Babies with reflux do not need to be on their front

Families should seek medical advice if they feel the position their baby is sleeping in is having a detrimental effect on their health. This decision should not be made by families alone.

Longer, deeper sleep is not safer sleep

Babies sleeping on their front sometimes seem to sleep longer and deeper. Their risk of SIDS is also much higher, probably for these same reasons. Parents and grandparents may have been slept this way themselves before the Back to Sleep campaign, but remind families that SIDS rates were significantly higher then. Babies need to be on their back.

Creating a clear, flat, separate sleep space

This piece of advice needs discussing with families to understand their circumstances and ensure they have planned for every eventuality. The safest place for a baby to sleep is in their own clear, flat, separate sleep space, such as a cot or Moses basket.

• Babies should sleep in the same room as their parent or carer (day and night) for the first six months
• Check if this is possible, and advise for the next best alternative if it is not
• They need a firm, flat mattress with no raised or soft sides and the cot should not be inclined, tilted or propped
• Clear sleep space means:
  • No pillows, quilts or duvets, bumpers or weighted bedding
  • No pods, nests or sleep positioners
• Make sure their baby’s head is kept uncovered so they don’t get too hot. Try to keep the room temperature between 16 and 20 degrees so the baby does not get too hot or cold and make sure bedding is appropriate for the time of year
• Place baby at the bottom of the cot so that baby cannot wriggle under covers – this is called feet to foot
• Ensure that the sleep space is kept clear of all items and there is nothing within reach of the space, e.g blind cords, nappy sacks and soft toys
• If the baby sleeps in a sling or baby carrier, make sure parents are aware of the TICKS guidance for safe use www.rospa.com/home-safety/advice/product/baby-slings/
• Babies should not be allowed to sleep in bouncers and babies should not be left sleeping in the car seat when not travelling in the car. Car seats are not to be used as sleep spaces in the house.

Keep babies smoke-free

Babies should be kept smoke-free both before and after birth. Smoking cigarettes during pregnancy or after birth can significantly increase the chance of SIDS.

• Discuss smoking with the family – this will have already been raised, but sometimes families need support to help make the decision to quit and you might make all the difference
• Refer for specialist support – families do not need to tackle this alone
• Question beyond the immediate family – what about visitors or other members of the family; are they aware of keeping the baby smoke-free?
• Discuss the link between bedsharing and smoking. It has been shown that the risk of SIDS is much greater if a baby shares a bed when either parent is a smoker, than if they were both non-smokers

Support breastfeeding

SIDS risk is halved in babies who are breastfed for at least two months.

• In the antenatal period, discuss infant feeding and how to get breastfeeding off to a good start. Let families know that breastmilk is all a baby needs for the first six months, and thereafter alongside other foods for two years and beyond.
• Refer families to support networks to help keep breastfeeding going, for example the National Breastfeeding Helpline on 0300 100 0212.
• For more information on supporting breastfeeding, visit: unicef.org.uk/babyfriendly or parentclub.scot/topics/feeding-your-baby

Of the babies who died whilst sharing a bed with an adult, 90% died in hazardous co-sleeping situations. Therefore, parents and carers should not fall asleep with their baby if:

• they have recently drunk any alcohol
• they or their partner smoke or the baby was exposed to smoking in pregnancy
• they have taken any drugs that make them feel sleepy or affect their awareness
• their baby was born prematurely or weighed under 2.5kg or 5½ lbs when they were born

In these scenarios, it is always best to put baby in their own safe separate sleep space, such as a cot or a Moses basket. Keeping the cot or Moses basket next to the bed might make it easier to do this. Anytime parents are under the influence of drugs or alcohol or medication that affects their alertness, a sober adult should be in charge of the baby. This should be discussed with all carers so they can plan ahead and avoid unplanned risky situations.

Place baby at the bottom of the cot so that baby cannot wriggle under covers – this is called ‘feet to foot'

Why these messages are important

SIDS rates are higher than they need to be - many sudden infant deaths occur with multiple risk factors.

Since safer sleep messages were introduced with the “Back to Sleep” campaign of the early 1990s, rates of SIDS have fallen dramatically. About half of the decline happened immediately after Back to Sleep, and the remainder has occurred more slowly over the last two decades due to additional infant care changes such as reduction in tobacco smoke exposure and increased breastfeeding.

We therefore know that following the available advice could significantly reduce the number of babies dying. This booklet, and the linked card and leaflet for families, focusses the messages to parents on those risk factors most closely linked to how babies are dying in the UK today. This is no longer the task of one group of professionals – we all need to focus on raising awareness of these messages and the reasons why they are important.

Talking to families

Safer sleep must be discussed with all families, regardless of their circumstances. These conversations will not always be easy, so we have produced two key documents to share with the families you work with:

• Quick reference card
• Safer sleep for babies - parent leaflet

Discussions around some areas of safer sleep advice can be challenging. There are no magic answers to making these conversations easier, but we must have them, and we know they make a difference. For each of the three main pieces of advice we provide more information and discussion tips.

Creating an environment where families can discuss their situations and concerns without fear of judgement is crucial. We must acknowledge that young babies wake and feed frequently in the night and reassure families this is normal, self-limiting, and that there is no need to find a ‘solution’ to this that might go against the safer sleep messages.

Bedsharing – universal advice

Bedsharing needs to be discussed with all parents and carers who have young babies as any of them might fall asleep with their baby accidentally, even if they don’t intend to. Babies can and do die in high- risk bed sharing situations. It could be just as dangerous to say never bed share as it is to say that all bedsharing is fine. We know from talking to parents that if they are told not to bed share they will then feel they cannot discuss what actually happens and will not therefore get the right advice. Neither approach has been successful at reducing high-risk bed sharing deaths.

Action plan:

1. Discuss with families

2. Ensure all families have access to a separate sleep space designed for a baby to sleep in

3. For families where SIDS risk is high, advise against bedsharing, and support with planning solutions for times when they might do so accidentally

4. For families where SIDS risk is low, make aware of the high- risk situations that anyone can get into on any given night (e.g. drinking alcohol), and refer to sources of information on making bedsharing safer: Basis, The Lullaby Trust and The UK Committee for Unicef (UNICEF UK) for your baby at night

5. Tell all families never to sleep on a sofa or armchair with their baby. Support with planning solutions for times when they might do so accidentally (e.g. moses basket next to the sofa, partner takes baby to cot)

6. Health visitors to request to be shown where the baby sleeps

7. Consider families where parents live apart. It is important that all parents are aware of safer sleep information.

Key principles:

• Be open and non-judgemental, as families bedshare at any given time for a wide variety of reasons. Shock messages that increase fear do not work
• Beware of assumptions - breastfeeding families are not automatically ‘safe’ bed sharers, and nor are formula fed babies always at a much higher risk. Both groups need guidance
• Explore – why is the family bedsharing? Do they have an alternative safe separate sleep space for their baby should they need it? Help them find one if not
• Plan – every family needs a plan to avoid unsafe accidental bedsharing, and those nights when something different happens
• Do not be afraid – to tell families if their circumstances mean they are in a high risk group and should not bed share (if they are smokers, if the baby was born prem or low birth weight, if they use drugs or drink alcohol)
• If a family’s risk for SIDS is high it is important to explain why. We know from our research and discussions with parents that they are much more likely to follow advice if they understand the reason
• Give all families the tools and information to make an informed decision with clear advice.

Key Messages:

• Put babies on their back for every sleep
• In a clear, flat, separate sleep place
• Keep them smoke-free day and night

If parents choose to share a bed with their baby they should discuss the following with a professional:

• Ensure there are no pillows, sheets, blankets or any other items in the bed with them that could obstruct their baby’s breathing or cause them to overheat. A high proportion of infants who die as a result of SIDS are found with their head covered by loose bedding
• Remind parents that if using a sleeping bag, no extra bedding is needed
• Check that baby cannot become trapped in the bedframe or headboard, wedged, fall out of bed or get stuck between the mattress and the wall
• Never leave their baby alone in the bed, as even very young babies can wriggle into a dangerous position.
• Keep pets away from the bed and do not have other children or babies (including multiples) sharing the bed

Bedsharing is not a risk-free activity, and parents must take responsibility for ensuring their baby’s safety. No studies have found that the parents' bed is safer than a cot beside the parents' bed.

Please use these links for further information on the following:

When babies start to roll lullabytrust.org.uk/sleepingposition

Premature babies lullabytrust.org.uk/premature

Slings rospa.com/home-safety/advice/product/baby-slings

For guidance on safe sleep for twins, triplets or more, visit: twinstrust.org/safe-sleep-factsheet

ParentClub/ Scotland’s Baby Box parentclub.scot/baby- box

Produced with the kind support of Public Health England