Safe sleep

For all newborns a safe environment for their sleeping is extremely important. A save sleeping position is even more important for preterm or low birth weight babies.

Before parents take their baby home, the health care team will explain parents everything about the optimal positioning of the baby. The team can explain everything about safe sleep. Some hospital units offer written information or special counselling on safe sleeping positions.

Parents should be (made) aware that the sleeping position they may have seen and practiced in the neonatal intensive care unit (NICU) may differ completely from the positioning they should practice at home: in the NICU the baby might be placed predominantly on the tummy (prone position), particularly when the baby has breathing difficulties. But the more the baby is nearing discharge, the more the baby will be placed on the back (supine position). Unless parents have received special instructions regarding the sleep position of their child at home, the following recommendations are important:

Parents of preterm babies should always consult their healthcare team on specific individual sleeping suggestions.

 
The baby should be placed on the back to sleep

The back position (supine position) has proven to be the safest sleeping position. 
Babies should not sleep on their tummy or their side at home, because this is associated
with the Sudden Infants Death Syndrome (SIDS).

 
The baby should sleep on a firm mattress and protected from bedding covering face, mouth, and nose

The baby should have a firm, non-polluting, air-permeable mattress. Waterbeds,
strollers and bags are not a suitable place for babies to sleep. Fluffy bedding, pillows,
blankets, stuffed toys should be avoided in the baby’s bed. For sleeping, a sleeping bag
and no blanket should be used.

 
Baby sleeping bags

Baby sleeping bags have many advantages compared to duvets. The baby is always properly covered, despite kicking and moving while sleeping. Baby sleeping bags are available for different room temperatures and different sizes for preterm babies and newborns, so that the baby does not have to feel cold nor have to sweat. With the right sleeping bag, the risk of overheating and bedding covering the baby’s face is much smaller.

Unlike blankets, babies cannot pull a sleeping bag over the head, mouth and nose, so the risk of breathing in their own exhaled, carbon monoxide rich air, is decreased. In a sleeping bag, which opens at the bottom, parents can change the nappy or undress the baby completely without waking the baby. The baby remains in a comfortable surrounding. With a sleeping bag, it is also more difficult for the baby to turn into the riskier prone position (i.e. lying on the tummy). As a rule of thumb for the right size of the sleeping bag it has established itself – body minus head length plus 10-15 cm for kicking and growing. It should be guaranteed that the neck is so small that the baby’s head cannot slip through. The armholes should not be too large either. When the baby feels cold, warmer clothes should be added, the combination of sleeping bag and blanket is not optimal.

 
The baby should be protected from overheating

The ideal temperature for babies to sleep at is at 16 °-18 ° C (i.e. 61 – 640 F), regular periods of airing should be ensured. The baby bed should not be placed directly next to the heater and should not be directly exposed to the sun. At home, babies do not need more clothing than adults. To sleep, the baby needs only a nappy, underwear and pajamas and even less at high temperature (e.g. in summer).

The baby should not feel hot to the touch of the parents and should not sweat. Neonatal units are kept very warm, so if the baby has just left the unit, parents need to gradually reduce the temperature of the room the baby sleeps in.

 
Co-sleeping should be avoided

Parents should avoid sleeping together with the baby in one bed in order to avoid overheating and the duvet covering the baby’s face, mouth and/or nose. The safest place for the baby to sleep is an own baby bed (cot or bassinet) with the parents in the same room. If parents wish to sleep closer to the baby to caress the baby without leaving the parents’ bed, the use of co-sleepers (baby beds that attach to the parents’ bed) would be recommended. The baby should sleep in the parents’ bedroom during the first two years of life. The sounds and movements of the parents positively stimulate the baby. For breastfeeding as well, it is advantageous if the cot is standing next to the parents’ bed.

An important aspect to have in mind when dealing with sleeping issues of babies is the Sudden Infant Death Syndrome (SIDS), also sometimes called “cot-” or “crib death”.

SIDS is the sudden, unexpected, and inexplicable death of an apparently healthy baby. It occurs most frequent during the first twelve months of a baby’s life. While SIDS is not an issue during the first weeks/months of life in the Neonatal Intensive Care Unit (NICU). However, soon after discharge, SIDS becomes an important topic parents should be aware of.

The exact cause of SIDS is still unknown. However, experts believe that it occurs from an interaction of multiple factors such as a particular stage in a baby’s development where the baby is most vulnerable, and environmental influences (tobacco smoke, getting tangled in bedding, a minor illness or a breathing obstruction). Nevertheless, parents can reduce the risk of SIDS by considering certain issues listed in the following recommendations.

 
Safe position at day- and night time

The baby must always sleep on the back (supine position). Until a few years ago, the side position (lateral position) was recommended in many countries as an alternative to sleeping on the back. However, further research has shown that the risk of SIDS increases in the lateral position by up to six times. Therefore, the side position should not be the sleeping position of choice for the baby. (In the supine position, the baby’s head is always a little inclined to the side. Measures to prevent a deformation of the baby’s head are described in the section below). International research clearly shows that sleeping on the tummy (prone position) significantly increases the risk of SIDS. Parents need to be aware that the positioning of their baby during the time (particularly the first weeks) in the NICU is different to the positioning of the baby at home. They should always seek the advice of their health care team in this matter before taking their baby home.

Despite the dangers of the prone or side-position during their baby’s sleep, parents should provide “tummy time” when the baby is awake. Yet, when doing so, they should never leave the baby unattended.

When the baby is awake and the parents can have an eye on their baby, the baby should be placed on the tummy or in a side-on position several times a day in order to train neck, shoulders and arms. Parents should ask their healthcare team about this topic before leaving the hospital with their baby.

The baby should sleep alone in a crib but in the parents’ room for ideally the first year of life. Moreover, the crib should have a firm, air-permeable mattress and not contain thick, fluffy padding (e.g. lambskin) nor pillows or big, fluffy toys/animals. These could cover the baby’s head, mouth or nose and impede the baby’s breathing. Instead of blankets it is recommended to use sleepingbags (s.a. safe sleep).

 
Body- and room temperature

The baby should be kept warm, not hot! Ensure adequate ventilation of both the bedroom and any other room where the baby spends a considerable amount of time (2-3 periods of airing with wide-open windows for about 5-10 minutes). The crib should not be placed directly next to the heater and should not be directly exposed to the sun. Also keep in mind that hot-water bottels, warm grains- or cherry-stone-pillows should not be placed in a baby’s crib either.

Your baby can best emit excess heat via the face and the exposed head. Therefore, while at home, please do not use a hat for your baby. You should always check whether your baby is dressed too warm. This also applies for car trips, bus rides, visits to department stores, and the like. Do not hesitate to dress your baby according to the circumstances. The best way to check whether your baby is too hot or too cold is by placing your hand on the back of their neck – hands and feet of babies are often cool and therefore no good indicator for this test.

 
Dummies

Despite their bad reputation, there is also a link between offering a dummy at bedtime throughout the first year of life and a decreased risk of SIDS. The dummy should be used when placing the baby in the crib. It does not need to be reinserted once the child has fallen asleep. Dummies that attach to baby clothing should never be hung around the baby’s neck to avoid strangulation.

If the baby refuses the dummy, the parents should not force the baby to take it. In those cases, parents can try to offer the dummy again when the baby is a little bit older. Due to the risk of suffocation, dummies should not be used with sleeping babies.

 
Further advice

Breast-feed your baby, if possible. Breast-feeding for at least six months, lowers the risk of SIDS.

Keep the baby away from cigarette smoke. Passive smoking has been linked with an increased risk of SIDS.