Safer Sleep for Infants Guidance
This guidance is applicable to the multi-disciplinary workforce that has contact with the parents, carers and their wider support network. It is to assist practitioners to discuss safer sleeping arrangements in order to support parents to make informed decisions regarding safer sleep and raise awareness to risk factors associated with Sudden Infant Death Syndrome (SIDS) and other fatal sleep accidents.
The purpose of this guidance is to:
- Provide a multi-disciplinary workforce in Lincolnshire with clear and consistent evidence-based information;
- Provider workers with the confidence and knowledge to facilitate an open and honest discussion to support parents and carers to make informed safer sleeping decisions for their babies;
- Ensure that consistent advice about safer sleeping arrangements is given across Lincolnshire by all workers;
- Ensure staff who visit households understand what constitutes an unsafe sleeping environment/practice and what support services they can access for the parents/care givers and their support networks;
- Ensure staff who have contact with families can identify babies who may be at greater risk of being in an unsafe sleep situation;
- To embed SIDS prevention and safer sleep within local safeguarding practice and wider strategies that support families in adverse circumstances;
- To reduce the number of babies and infants in unsafe sleep situations;
- To reduce the death rate of babies and infants in Lincolnshire.
The guidance presents evidence on a wide range of potential risk factors and family circumstances that are associated with SIDS. Though SIDS rates have declined over the last 10 years, there is evidence of widening health inequalities with rates of SIDS being highest in the most deprived areas (The Lullaby Trust, 2018). The evidence reviewed by the policy group support this. Infants appear to be more vulnerable to SIDS or other fatal sleep accidents where families are under stress – we found links with mental health problems, substance misuse, overcrowding, teenage parents, changes to family circumstances, deprivation, domestic abuse and involvement of children's services. It demonstrates that safer sleep is not just the business of the childcare workforce: it is everyone's responsibility.
Evidence also suggests that, in many cases, families who experience these tragedies are already known to children's services and/or safeguarding teams (Garstang and Sidebotham, 2018) and are aware of the safer sleep messages (National Child Safeguarding Practice Review Panel, 2020). This document therefore discusses how safer sleep messages are communicated to families in a way that changes behaviour (see Section 5, Having Effective Safer Sleep Conversations).
For the purpose of this document the following definitions will apply:
Sudden Infant Death Syndrome (SIDS)
Sudden infant death syndrome is defined as the sudden unexpected death of an infant less than 1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and clinical history (Krous, 2004 taken from NICE, 2014).
Sudden Unexpected Death in Infancy (SUDI)
An acronym used to categorise all sudden unexpected deaths in infancy, this term includes SIDS.
Other fatal sleep accidents
These deaths are similarly sudden and unexpected, but unlike SIDS may have a cause assigned, such as suffocation or strangulation in bed in the context of bed-sharing or unsafe items in the sleep environment. The distinction between SIDS and a sleep-related accident can be unclear even after investigation, but the risk factors are the same.
Deaths in infancy
Term relates to deaths of babies under the age of one year.
A parent, grandparent, foster carer/s babysitter or any other person responsible for the baby at that particular time.
A person or group of people who provide emotional and practical help.
Anyone working in Lincolnshire coming into contact with families who reside in Lincolnshire.
An adult and a baby sleeping together on any surface (such as a bed, chair or sofa). This can be for any period of time, day or night.
Rolling onto an infant and smothering them in bed or on a chair, sofa or beanbag.
A mat or cushion with raised supports or pillows attached to each side, designed to keep babies in a specific position when sleeping.
Pods or nests
Sleep surfaces with raised or cushioned areas.
Since parent and carers have been following risk reduction advice first promoted in the early 1990s, the number of infants dying of SIDS has fallen significantly. Yet on average 4 babies die of SIDS every week in the UK. In 2017, 183 babies died of SIDS in England and Wales (Office for National Statistics (ONS)). Despite this being the lowest on record, rates in the East Midlands have increased (The Lullaby Trust, 2020). In Lincolnshire we have consistently seen 3-4 sudden unexpected, unexplained infant deaths per year over the last three years, up until 2019/20 (Saggiorato, 2020).
Previous UK data suggests (UNICEF, 2019):
- Around half of SIDS babies die while sleeping in a cot or Moses basket;
- Around half of SIDS babies die while co-sleeping. However, 90% of these babies die in hazardous situations which are largely preventable.
Although the cause of SIDS is not known, there are specific factors that make SIDS more likely (NICE, 2015). Safer sleep messages can appear complex, controversial and at odds to the reality of parenting. However, it is important that family-centred communication is provided in order to ensure all parents and carers have access to clear and consistent information on how to reduce the risks of SIDS. If safer sleep advice is followed, it is possible some babies' lives could be saved.
4. Current Evidence-Based Information to be Provided to All Baby's Carers
Since we do not know what causes SIDS, there is no advice that guarantees the prevention but it is possible to reduce the risk. Remember, every sleep needs to be a safer sleep – whether baby is sleeping at night, or during the day, at home or away from home.
The below advice should be given to all who care for baby within the family and wider support group. It is likely that new parents will seek advice from their wider family and it is important that key figures are aware of safer sleeping information.
The current safer sleep campaign (correct as of September 2020) has been developed by Lullaby Trust, Public Health England (PHE), Basis and UNICEF and focuses on 3 key pieces of advice.
The number of babies who die of SIDS could be reduced dramatically if families:
- Put babies on their BACK for every sleep;
- In a CLEAR, FLAT SLEEP SPACE;
- Keep them SMOKE FREE day and night.
These 3 key pieces of advice are supported by the following evidence-based messages which all staff and volunteers working with families should be aware of:
- Place your baby to sleep in a cot or Moses basket in the same room as you for the first 6 months, day and night;
- Use a firm, flat, waterproof mattress in good condition. If baby is asleep in a car seat or pushchair, move them onto a firm, flat surface;
- Keep the sleep space clear: no pillows, quilts, duvets, soft toys or cot bumpers;
- Babies should be placed on their back in the 'feet to foot' position (i.e. placing the baby's feet to the foot of the cot to avoid them wriggling down under the covers);
- Don't cover your baby's face or head while sleeping or use loose bedding;
- Avoid letting your baby get too hot. A room temperature of 16–20ºC is recommended;
- Keep your baby smoke free during pregnancy and after birth;
- Breastfeed your baby.
It is most important to explain that around half of all parents will sleep with their baby at some point, be this planned or unplanned, and although SIDS is very rare it is much more likely to happen in certain circumstances. If no baby co-slept in hazardous situations, we could potentially reduce co-sleeping deaths by nearly 90% (UNICEF, 2019).
- Never sleep on a sofa or in an armchair with your baby;
- Don't sleep in the same bed as your baby if:
- Either you or your partner smoke (even if not in bedroom), or if the mother smoked during pregnancy;
- Either you or your partner has recently drank alcohol;
- Either you or your partner has recently taken drugs (including medications that make you drowsy);
- Your baby was born prematurely (37 weeks or less);
- Your baby was of low birth weight (2.5kg or 5 ½ lbs or less).
Parents who choose to co-sleep should be aware of steps they can take to make it safer:
- Keep your baby away from the pillows;
- Make sure your baby cannot fall out of bed or become trapped between the mattress and wall;
- Make sure the bedclothes cannot cover your baby's face or head;
- Don't leave your baby alone in the bed, as even very young babies can wriggle into a dangerous position (UNICEF, 2019).
5. Having Effective Safer Sleep Conversations
National advice on reducing the risk of SIDS and other fatal sleep accidents has been clear and consistent over many years. A national review into SUDI in families where the children are considered at risk of significant harm noted that while there is no evidence that this advice is not given routinely, it is not, for whatever reason, clearly received or acted on by some of those families most at risk (National Child Safeguarding Practice Review Panel, 2020). It is important therefore to reflect on how safer sleep messages are communicated to families.
Evidence shows that interventions are most effective when they are personalised, culturally sensitive, enabling, empowering, relationship building, interactive, accepting of parental perspective, non-judgemental and are delivered over time (National Child Safeguarding Practice Review Panel, 2020).
The Lullaby Trust identifies the following principles that should be applied when discussing safer sleep with families. These principles are also reflected in the NICE guidance on behaviour change.
Be open and non-judgemental
Creating an environment where families can discuss their situations and concerns without fear of judgement is crucial.
Focus on assessing needs rather than making assumptions. For example, breastfeeding families are not automatically 'safer' co-sleepers and neither are formula fed babies always at a much higher risk. Both groups need guidance that's tailored to their needs.
Shock messages that increase fear do not work. For example, shocking messages that imply that all/any co-sleeping leads to death are not helpful. They do not reflect the evidence, and they frighten parents and staff, induce guilt and close down honest conversations (UNICEF, 2019).
A relationship-based approach – developing supportive yet challenging relationships – can facilitate more effective safer sleep conversations. Parents are more likely to act on advice from someone they trust and believe.
Safer sleep conversations and advice should be tailored to each family's needs. Take time to understand the family's experiences and circumstances. What is influencing the family's sleep practices?
Conversations should combine empathy and support with appropriate challenge. Do not be afraid to tell families if their circumstances mean their baby is at higher risk.
Remember that it isn't helpful to tell parents what they must or mustn't do; instead, listen carefully and offer information appropriate to their needs (UNICEF, 2019).
It may be necessary to focus safer sleep conversations and information on risky situations, and to initiate 'what if' discussions about arrangements to ensure a safer sleep environment. Every family needs a plan to avoid potentially hazardous sleep situations on those occasions when something different happens.
For example, questions could include: what's happening tonight? Having a drink? Going on holiday or staying with friends? Letting your partner sleep? What's the family's plan if baby is unwell?
We know from research and discussions with parents that they are much more likely to follow advice if they understand the reason.
It might be helpful to some families to explain normal baby behaviour and discuss expectations. Acknowledge that young babies wake and feed frequently in the night and that this is normal and not modifiable, as young babies are not capable of 'learning' to defer their needs. Accepting this reality can be helpful, as parents are reassured that their baby is normal and they aren't doing anything wrong. It can also relieve the pressure to find 'solutions' (UNICEF, 2019).
Give clear advice
Information must be provided in such a manner that it is understood by the baby's carer. For those babies' whose carers do not understand English, an approved interpreter should be used where possible and appropriate. Families with other language and communication needs, including learning disabilities, should be offered information in such a way to aid understanding. See Section 10, Resources and Links.
6. Risk Factors and Reducing the Risk
It is important to acknowledge that we don't always know why something presents as a risk factor to SIDS, only that research over a number of years tells us that certain circumstances are associated with an increased risk of SIDS.
The following chapter presents a summary of evidence on risk and protective factors associated with SIDS, divided into the following sections:
- Factors associated with an increased risk of SIDS;
- Factors associated with a decreased risk of SIDS;
- Family circumstances associated with SIDS.
We have summarised evidence presented in The Lullaby Trust, Evidence Base, with additional information taken from literature reviews and contributions from agencies in the policy group.
The evidence will inform the actions that LSCP and its partner agencies will undertake to reduce the number of babies and infants in unsafe sleep situations in Lincolnshire.
Factors associated with an increased risk of SIDS
Placing an infant to sleep on their stomach (prone) or side is significantly associated with an increased risk of SIDS.
Infants who usually sleep on their back (supine) but are unusually placed on the front (prone) or side are at increased risk of SIDS.
Prone and side sleeping is particularly dangerous for babies born with low birth weight, both those born preterm (before 37 weeks) and those with intrauterine growth restriction.
There is no evidence that placing healthy babies on their back to sleep puts them at greater risk of death through aspiration of vomit and choking.
Parents/carers concerned about head deformities such as plagiocephaly (asymmetric flattening of the infant skull) may resort to non-supine sleep positions or use pillows marketed as preventative aids, despite both being risk factors for SIDS.
As babies get older the sleep position cannot be controlled, as they will move to find the sleep position they find most comfortable.
- Parents should be advised that placing an infant to sleep on their stomach or side is significantly associated with an increased risk of SIDS. The risk is further increased in babies who are either pre-term, low birth weight and those with intrauterine growth restriction;
- Infants should always be placed on their back to sleep at the start of every sleep period;
- It is important that babies are put on their backs consistently as part of their regular sleep routine;
- Babies should be allowed supervised time in the prone position when awake to avoid development of plagiocephaly and aid motor development.
- The Lullaby Trust, The best sleeping position for your baby;
- The Lullaby Trust, Reducing the risk of SIDS for premature babies.
Maternal smoking both during pregnancy and after the baby is born increases the risk of SIDS. The risk appears to be dose related: the more cigarettes smoked, the higher the risk of SIDS.
The risk of SIDS is greatly increased in association with a combination of co-sleeping and smoking by either parent, even if they do not smoke in the bed.
Babies who grow up in a smoky atmosphere have an increased risk of SIDS. A smoky environment is anywhere near someone who is smoking, or in a room where someone has smoked.
- Parents should not smoke during pregnancy or after birth; this applies to both parents;
- Co-sleeping is unsafe if either parent smokes or the mother has smoked in pregnancy;
- Postnatal exposure to second-hand smoke also puts a baby at risk; therefore it is important to keep a baby out of smoky atmospheres;
- Remind parent/carers that nicotine or smoke will not be visible, but does remain on clothes, in hair, carpets and sofas (third-hand smoke), for hours and or even days after a cigarette is put out. There is currently not enough research to understand how harmful this may be to your baby;
- Should people continue to smoke, advise on how to do this more safely or change smoking habits: ensure the environment is a smoke-free zone and people smoke outside. Remember it is illegal to smoke in a car or other vehicle with any children under 18 present.
At the first (booking) appointment with the midwife, pregnant women are asked their smoking status. If they are a smoker they are automatically referred to the smoking cessation service currently provided by One You Lincolnshire. If this referral is declined, women can be referred to this service at any time in pregnancy and after birth.
Anyone above the age of 12yrs+ who lives, works or is registered with a Lincolnshire GP can self-refer in to the Smoking Cessation Service.
Referral can be done in any of the following places:
Healthcare professionals can also refer their patients with consent. Referral forms are on SystmOne and E-MIS.
There is no evidence yet relating to electronic ('e') cigarettes and the risk of SIDS although it is hoped that these may be safer than standard tobacco cigarettes. The Smoking in Pregnancy Challenge Group recommends that pregnant women who find using an e-cigarette helps them to remain smoke-free should not be discouraged from doing so. The safest option is to stop smoking but if parents are unable to do this then e-cigarettes may be safer in pregnancy and after birth by reducing exposure to smoke.
As there is no direct research on using e cigarettes and SIDS, it is recommended that parents do not co-sleep with baby if they use e-cigarettes.
Sharing a sofa or chair with an infant is associated with an extremely high risk of SIDS. This has been shown to be more risky environment than an adult bed.
Co-sleeping is much more dangerous when parents smoke or have smoked during pregnancy.
The risk of co-sleeping for non-smoking parents mainly affects infants with low birth weight (2.5Kg) or infants born pre-term (<37 weeks). Younger infant age (under 3 months old) has also been found to be associated with an increased risk of SIDS even where babies were breastfed, where neither parent smoked, and no other risk factors for SIDS were present.
The risk of SIDS is increased where there is co-sleeping and a parent has used alcohol or drugs.
Practitioners must recognise that many parents choose to co-sleep for a number of reasons, and in some cultures it is common practice. It is also important to recognise that co-sleeping can happen both intentionally or unintentionally. Understanding the family's experiences and circumstances with regards to co-sleeping is important. To tell parents that they should never co-sleep, or to not discuss co-sleeping, is not safe and could increase the risk of baby being put into unsafe co-sleeping situations.
- Babies should be placed on their backs for sleep, in a clear safe space, in the presence of a caregiver day and night;
- Parents should be made aware that co-sleeping is associated with an increased risk of SIDS where:
- Either parent smokes;
- Either parent has consumed alcohol or taken drugs (including medications that may make them drowsy);
- The baby was premature;
- The baby was low birth-weight.
- Co-sleeping on a sofa or armchair is significantly more unsafe than on a bed.
- Parents who choose to co-sleep should be aware of steps they can take to make it more safe:
- Keep your baby away from the pillows;
- Make sure your baby cannot fall out of bed or become trapped between the mattress and wall
- Make sure the bedclothes cannot cover your baby's face or head;
- Don't leave your baby alone in the bed, as even very young babies can wriggle into a dangerous position (UNICEF, 2019).
Co-sleeping when extremely tired
Some safer sleep guidance, including some publications by the Lullaby Trust, advise parents not to sleep in the same bed as baby if they are extremely tired. This advice has been removed from the key messages section of this policy because it was felt by the policy group to be potentially confusing for parents, with an unclear evidence base. This policy focuses on the UNICEF message that co-sleeping deaths could be reduced 90% if no baby slept in hazardous situations (see Section 4, Current Evidence-Based Information to be Provided to All Baby's Carers).
- The Lullaby Trust, Co-sleeping with your baby;
- Unicef, Co-sleeping and SIDS: A Guide for Health Professionals.
Babies are at increased risk of SIDS when they get too hot – this can be from a high room temperature, excessive overwrapping or both. Overwrapping can be due to the level of bedding and/or clothing.
Wearing hats for sleep during the day or night can increase baby's risk of SIDS.
- Babies should not wear hats indoors or when asleep;
- Babies should be checked to ensure that they are a suitable temperature and clothes and bedding are appropriate for the room temperature;
- A room temperature of 16-20 degrees centigrade is suggested.
The evidence for swaddling and SIDS is unclear and further research is needed. Parents/carers who wish to swaddle their baby should seek advice on how to do this correctly. The latest advice on swaddling is as follows:
If you decide to adopt swaddling, this should be done for each day and night time sleep as part of a regular routine:
- Use thin materials;
- Do not swaddle above the shoulders;
- Never put a swaddled baby to sleep on their front;
- Do not swaddle too tight;
- Check the baby's temperature to ensure they do not get too hot.
Loose bedding such as quilts, pillows and duvets is associated with an increased risk of SIDS. These items can cover baby's head and cause suffocation.
Soft sleep surfaces such as soft mattresses (as opposed to average and firm mattresses), and quilts, pillows and sheepskins used as sleep surfaces, are also associated with a significant increase in the risk of SIDS.
Some studies have noted an association between second-hand mattresses and SIDS.
- Babies should sleep on a firm, flat mattress that is clean and in a good condition, ideally new. A mattress with a waterproof cover will help parents to keep it clean and dry;
- It is important to keep a baby's head uncovered while they are sleeping. Parents should be advised to place their baby on their back in the 'feet to foot' position (with their feet touching the bottom of the cot or Moses basket) and the use of pillows, quilts and duvets should be avoided;
- The mattress should be well-fitted to the cot with no gaps around the sides. Using a mattress specifically designed for the cot will ensure the best fit;
- If a second-hand mattress is used make sure the mattress was previously completely protected by a waterproof cover, with no rips or tears.
See also: Section 7, Infant Products on other infant sleep products and surfaces.
- The Lullaby Trust, The best mattresses and bedding for your baby;
- The Lullaby Trust, A clear cot is a safer cot.
Some evidence shows that heavier alcohol consumption and drug-taking, either in pregnancy or after birth, appears to be related to an increased risk of SIDS, although other SIDS risk factors such as smoking, low socioeconomic status, poor antenatal care and low birthweight are often also involved.
As noted above, there is evidence of increased risk of SIDS is increased where there is co-sleeping and a parent has used alcohol or drugs.
Substance misuse by a parent or carer is widely recognised as one of the factors that puts children more at risk of harm. The biggest risk posed to babies and children is that parents, when under the influence of drugs or alcohol, are unable to keep their child safe (including overlay through co-sleeping).
Failing to follow this advice may constitute a safeguarding concern and require professionals to take further advice on any action which may be required. If there are concerns about significant harm, normal safeguarding procedures and processes apply (see also: Section 9.1, Early Help Assessment).
The policy group reviewed evidence on the impact of prescription or over-the-counter medication and SIDS. Most guidelines make reference to 'illicit' drugs, though reference is made to any substance which makes a parent drowsy or unresponsive which could create a hazardous co-sleeping situation.
- Women have been advised to abstain from drinking alcohol and taking drugs in pregnancy. No 'safe' level of alcohol has been established, so it is advisable for pregnant women to abstain from alcohol completely;
- Parents should carefully consider infant care arrangements for the whole night if they plan to drink or use drugs recreationally, including avoiding co-sleeping. Parents should be made aware that co-sleeping is associated with an increased risk of SIDS where either parent has consumed alcohol or taken drugs (including medications that may make them drowsy).
Receiving timely and regular antenatal care is associated with a lower risk of SIDS. All women should receive the recommended number and schedule of appointments during pregnancy.
Receiving adequate antenatal care is especially important for women who have previously lost a baby to SIDS, as they are more likely to experience pregnancy complications such as preterm birth and intrauterine growth restriction in subsequent pregnancies, increasing the risk for recurrent SIDS.
The Better Births Lincolnshire programme aims to improve access to antenatal pregnancy care through a network of local maternity hubs and online self-booking.
Factors associated with a decreased risk of SIDS
There is a significant decrease in the risk of SIDS when infants are placed in the same room as their parents, but they do not share the same sleep surface.
- Parents should be advised that a baby should have a clear safe space to sleep in for the first six months and should sleep in the same room as the parents, day and night.
Breastfeeding lowers the risk of SIDS. Breastfeeding for at least 2 months halves the risk of SIDS but the longer baby is breastfed, the more protection it will give baby.
Even breastfeeding for a short time can help reduce the risk of SIDS. Both partial and exclusive breastfeeding have been shown to be associated with a lower SIDS rate, but exclusive breastfeeding was associated with the lowest risk.
- Breastfeed your baby.
- The Lullaby Trust, Breastfeeding and SIDS;
- Unicef UK Baby Friendly Initiative - Caring for your baby at night: A health professional's guide.
Breastfeeding support for parents:
- United Lincolnshire Hospitals NHS Trust, Sources of breastfeeding support in Lincolnshire during the Coronavirus pandemic;
- United Lincolnshire Hospitals NHS Trust, Postnatal leaflets and videos;
- NHS.UK, Breastfeeding: the first few days;
- UNICEF, Support for Parents;
- National Breastfeeding Helpline 0300 100 0212;
- Breastfeeding Friend. Sign in with Facebook and message the Start4Life Breastfeeding Friend chatbot for fast, friendly, trusted NHS advice anytime, day or night. Also works with Google Assistant and Amazon Alexa.
Some research suggests it is possible that using a dummy when putting a baby down to sleep could reduce the risk of sudden infant death.
- Breastfeeding should be established for at least a month before the dummy is introduced. Breastfeeding is a protective factor against SIDS (see 6.9);
- Parents could consider offering a dummy when settling the baby to sleep;
- If baby uses a dummy as part of their sleep routine it should be given for every sleep, day and night;
- Stop giving them the dummy when they're between 6 and 12 months;
- Remove any attachments on the dummy;
- Never coat the dummy (for example, with something sweet);
- Don't force baby to take a dummy or put it back in if baby spits it out;
- Don't offer a dummy during awake time.
Immunised infants have a significantly lower risk of SIDS.
- Parents should be advised to ensure their infant receives all scheduled vaccinations.
Further information on scheduled vaccinations is in the Personal Child Health Record (or Red Book) given to parents/carers at a child's birth.
Family circumstances associated with SIDS
Babies born to mothers below the age of 20 are three times more likely to die from sudden infant death syndrome (ONS, 2017).
The Lullaby Trust provides dedicated support for young parents. See: Little Lullaby website.
Several studies have identified parental mental illness as a characteristic of families affected by SIDS.
Most research has focused on mothers, but growing evidence suggests that the fathers' mental health is also a factor. Mental health is impacted significantly where abuse of drugs and alcohol are factors. Health care professionals should ensure that families where mental health problems are identified in either partner, in particular women with perinatal depression, are appropriately treated and are provided with clear advice on infant care practices that may prevent SIDS.
The most common mental health problems that women in the perinatal period experience are depression and anxiety. Steps2change is improving access to psychological therapy (IAPT) services. See: Steps2change Lincolnshire, Self-referral.
In addition the LPFT Perinatal Mental Health Service works with women who have, or are at high risk of developing a severe mental illness. In addition to their specialist role they can advise on medication in pregnancy and feeding. Health professionals are encouraged to call the team duty line directly on 01522 340160 ext 227 or e-mail email@example.com and discuss any concerns they have with a clinician.
Alongside the overall reduction in incidence, however, there has been a steady shift towards these tragedies happening predominantly in families from deprived socioeconomic backgrounds (Child Safeguarding Practice Review Panel, July 2020).
A UK case-control study of factors influencing the risk of SIDS found an association between overcrowded housing conditions and co-sleeping among younger infants (Blair et al., 1999). Some non-UK studies have found that social and environmental factors, such as living in overcrowded accommodation, may contribute to infants sleeping on an unsafe surface (British Columbia Coroners Service, 2009) or the lack of a safe infant sleep space (Chu et al., 2015).
A recent review into SUDI in families where the children are considered at risk of significant harm found that disrupted routines were a common in SUDI cases and often led to parents not following safer sleep advice, either because they were unable to, or because they did not consider it relevant in the circumstances. Planning for infant safety during disrupted routines might avoid rare but very high scenarios ((Child Safeguarding Practice Review Panel, July 2020).
A qualitative analysis of serious case reviews into unexpected infant deaths found that domestic abuse was common in families with SUDI. Also common were concerns about neglect and established patterns of non-engagement with professionals, with many families already well known to services (Garstang and Sidebotham, 2018).
7. Infant Products
There is little evidence on car seats and other sitting devices and SIDS. However, data indicates that improper use of such devices can pose a risk of accidental asphyxia or strangulation. 'Other sitting devices' could include baby bouncer, rocker or swing chairs and pushchairs.
- Car seats are necessary for transporting infants in a moving vehicle, but they should only be used for transportation;
- If an infant falls asleep in a car seat or sitting device they should be moved to a flat surface when it is safe to do so;
- Car seats and sitting devices should not be placed on high or soft surfaces – they could fall off or topple and cause injury;
- When travelling, stop for regular breaks to check on baby, take them out of the car seat and let them stretch and move around.
A sleep positioner is a mat with raised supports or pillows attached to each side, designed to keep babies in specific positions. Pods or nests are softer types of sleep surface with raised or cushioned areas. Research suggests that parents use sleep positioners, pods and nests to prevent SIDS, reflux, rolling and plagiocephaly (flat head) (LSCP, 2018).
Although no research has been conducted to evaluate whether any such products increase or decrease the risk of SIDS, analysis of consumer safety reports in the US has implicated some products in infant deaths involving suffocation, strangulation and entrapment.
Some sleep positioners are designed to keep baby on their side or prone when sleeping. Placing an infant to sleep on their stomach (prone) or side is significantly associated with an increased risk of SIDS (see above).
It should also be noted that while mattresses have to comply with specific British or European safety standards, sleeping positioners, pods, nests or wedges do not have to comply with these same standards. There is evidence to show that soft sleep surfaces are associated with a significant increase in the risk of SIDS (see above).
- New infant sleep products are coming onto the market all the time. Practitioners should encourage parents to sleep baby on a firm, flat mattress to reduce the risk of SIDS and accidents, for every sleep;
- The sleep space should be kept as clear as possible to reduce the risk of accidental strangulation, suffocation or entrapment.
Cot bumpers have been implicated in infant deaths and non-fatal child accidents. Infants can become wedged between the bumper and cot mattress, get into a position where their face is pressed up against the soft padding of the bumper, become entangled in the bumper or its ties, or, for older infants, fall from the cot after climbing on the bumper.
- Do not use cot bumpers;
- An infant's sleep environment should be kept as clear as possible to reduce the risk of accidental strangulation, suffocation or entrapment.
There is currently a lack of data on the use of baby slings and SIDS, though there have been cases of infant fatalities attributed to sling use and suffocation and/or overwrapping. Younger infants may be particularly at risk.
- The Consortium of UK Sling Manufacturers and Retailers provides the following advice to baby sling wearers: Keep your baby close and keep your baby safe. When you're wearing a sling or carrier, don't forget the T.I.C.K.S acronym:
- In view at all times
- Close enough to kiss
- Keep chin off the chest
- Supported back.
There have been very few studies that have investigated the use of sleeping bags; however they appear to be at least as safe as sheets and blankets when no other risk factors are present. When well-fitted around the neck and chest they could prevent head-covering and rolling into the prone position (The Lullaby Trust Product Guide).
8. Related Issues
Some carers lose control when baby's crying becomes too much and go on to shake a baby, which can result in severe head trauma. The ICON programme is all about helping people who care for babies to cope with crying. ICON stands for:
I – Infant crying is normal
C – Comforting methods can help
O – It's OK to walk away
N – Never, ever shake a baby
The ICON program can be delivered by health visitors, midwives and GPs as well as via social media, and is led locally by Lincolnshire ICB.
See: ICON website.
Although the exact role of infant infection in SIDS is not well understood, it is recommended that medical advice should be sought if a baby shows signs of illness that persist for more than 24 hours. Some useful resources are available to help parents decide when to seek medical help.
- NHS.UK, Is your baby or toddler seriously ill?
- The Lullaby Trust, Baby Check is your baby really ill?
Propped bottle feeding is when a baby is bottle fed by leaning the bottle against a pillow, blanket or other support, rather than holding the baby and the bottle while feeding. If a baby is prop fed, they may breathe in the liquid and choke, rather than swallow it. Also, if a baby is fed whilst leaning back or lying down, liquid can go down into the lungs rather than the stomach.
The number of babies dying from breathing in or choking on milk is uncertain, but where large amounts of milk have been found in babies who died suddenly, this was thought to be an important part of the cause of death (Iwadate et al., 2001).
Babies should be bottle fed responsively. The baby should be held throughout the feed in a semi-upright position. The carer should observe for signs the baby needs a break and should not force baby to finish a bottle. This will ensure safety, avoid over feeding and make bottle feeding a pleasant experience for baby.
- Do not prop feed. Hold baby close in a semi-upright position throughout the feed.
- UNICEF, Infant formula and responsive bottle feeding;
- UNICEF, Support for Parents;
- UNICEF, Bottle feeding resources;
- NHS.UK, Start4Life Bottle Feeding and Breastfeeding;
- NHS.UK, Healthy Start.
Care of Next Infant
The CONI programme supports families before and after the birth of their new baby. The Lincolnshire programme is coordinated by LCC 0-19 Children's Health Service alongside ULHT, where available a named paediatrician would also support this role.
Unintentional injuries in the home – such as accidental falls, poisoning, burns and scalds, drowning, and fatal sleep accidents caused by suffocation – are a leading cause of death and disability for children under 5 (Public Health England). As with SIDS, children living in families with deprivation and/or adverse circumstances are disproportionately affected.
Lincolnshire's Child Home Injury Prevention (CHIP) scheme aims to support families to keep their children safe from home accidents, through training for practitioners, assessment tools and provision of safety equipment.
9. Agency Roles and Responsibilities
Each organisation has a role to play in promoting safer sleep. This will be different between organisations with some having a greater role than others. To reduce the risk of further deaths we need everyone in contact with families in Lincolnshire to help ensure safer sleep advice is followed.
For services working directly with families, this policy recommends that:
- Practitioners are aware of this policy, know the key messages and receive safer sleep training;
- Safer sleep training is incorporated into the practitioners' training programme and CPD;
- Practitioners discuss safer sleeping arrangements with families, and their wider support network, at each opportunity;
- Practitioners have access to safer sleep resources that can be used with/given to families;
- Safer sleep is incorporated into the appropriate service operational guidance and procedures, or risk assessment tools;
- Safer sleep discussions and actions are documented;
- Agencies promote safer sleep message through their communication channels;
- For settings where infants are put to sleep, safer sleep is incorporated into its relevant policies and risk assessments.
The above would apply to:
- Midwives have discussions with parents in the antenatal period, during their hospital stay and in the early postnatal period about safer sleep;
- See appendix A for the ULHT Safer Sleep in Hospital policy;
- Health visitors;
- In-line with guidance practitioners should deliver safer sleep advice at each of the following visits:
- Antenatal contact;
- Primary birth visit;
- All subsequent follow up contacts.
- Early Help Workers;
- Early Years Workers;
- Social Workers;
- Child minders;
- Nurseries and other early years settings;
- Family support volunteers or peer supporters.
For services that have brief contact with families but may observe unsafe sleeping practices, this policy recommends that:
- Staff have training to understand the principles of safer sleep and why this relates to their area of work;
- Staff understand that infants are at increased risk when there is a change of circumstances (which is the likely reason the service has got involved);
- Safer sleep is incorporated into the appropriate service operational guidance and procedures, or risk assessment tools;
- Staff know how to complete the Early Help assessment tool which assists them to support families and encourage open discussions (see Section 9.1, Early Help Assessment).
According to evidence, this would apply to:
- Housing teams;
- Mental health support services;
- Emergency services;
- GP practices;
- Probation service;
- Adult services (Learning Disabilities Team);
- Domestic abuse services;
- Drug and alcohol services.
Some services require specific guidance:
Neonatal nurses. When babies are preterm or very sick, they may be positioned on their front, side or back and aids to support their bodies such as positioners may be used. Neonatal Unit staff discuss safe sleep with parents while their baby is on the Neonatal Unit and also prior to discharge from the Neonatal Unit. These discussions include highlighting the particular risks of co sleeping when the baby is preterm or low birth weight. Parents are provided with the Lullaby Trust Safer sleep advice prior to discharge both in paper format and available electronically via a QR code linking to maternity postnatal leaflets webpage.
Fostering and adoption services should be aware of the increased risk of SIDS when a parent has smoked or consumed drugs or alcohol in pregnancy. This should be part of the risk assessment process and discussed with the fostering/adopting family.
Smoking cessation service should be aware of the association between smoking and SIDS, and ensure this is communicated to the family.
Over the border midwifery services will see Lincolnshire residents and so should be made aware of this policy, including:
- Norfolk and Norwich University Hospitals NHS Foundation Trust;
- Northern Lincolnshire and Goole NHS Foundation Trust;
- Northwest Anglia Foundation Trust;
- Nottingham University Hospitals NHS Trust.
Where professionals identify concerns that would benefit from early intervention this should be discussed with the parent/legal guardian at the earliest opportunity. Consent should be gained for a Early Help Assessment to be completed with the family. Further information and guidance is available within the Early Help and Team Around the Child Documentation.
If a child is believed to be at immediate risk of significant harm, safeguarding action should be taken. Refer directly to the Children's Services Customer Service Centre on 01522 782111. If there are immediate risks to the baby's safety or that of other children in the household, then this must be reported without delay to the Police.
For emergencies use 999. For urgent/immediate reporting use 101.
If professional judgement identifies a significant risk then it is likely that there will be serious or complex needs or Child Protection concerns requiring an immediate referral to Children's Services (see Safeguarding Referrals Procedure). Children's Services must hold a Strategy Discussion whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm whether or not it appears that a criminal offence against a child has been committed.
10. Resources and Links
The Lullaby Trust - safer sleep advice and resources.
Consideration should be given where English is not the first language of parents or where parents have any communication difficulties. The Lullaby Trust 'Safer sleep for babies' leaflets are available in many different languages and in picture form.
Basis - Baby sleep info source: resources for parents. Including safer sleep advice for twins, triplets and more.
UNICEF - sleep and night time resources.
Safer Sleep Week - usually takes place annually in March and is coordinated by The Lullaby Trust. It aims to raise awareness of SIDS and equip parents with information how they can reduce the risk. Resources are made available to support local campaigns.
Mum and Baby App - Personal preferences for each stage of the maternity journey can be documented, stored within the app for sharing with midwives, nurses or doctors, generating conversations that support collaborative and personalised care plans, crucially, the clinically validated mum & baby app provides a single point of access for information on booking in the local area. The app also includes links to information and guidance for expectant parents including Safer Sleep Leaflets produced by the Lullaby Trust.
Baby Buddy App - The Baby Buddy app guides parents through pregnancy and the first 6 months following baby's birth. It is designed to help parents look after baby's mental and physical health.
Blair, P., Fleming, P., Young, J., Nadin, P., Berry, P., Golding, J., Smith, I., Platt, M. (1999). Babies sleeping with parents: Case-control study of factors influencing the risk of the sudden infant death syndrome. British Medical Journal vol. 319 (no. 7223), pp. 1457-1461.
Child Death Review Unit. (2009). Safe and Sound: A Five Year Retrospective. Child Deaths in British Columbia. British Columbia Coroners Service.
Child Safeguarding Practice Review Panel. (2020). Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm.
Chu, T., Hackett, M., Kaur, N. (2016).Housing influences among sleep-related infant injury deaths in the USA. Health Promotion International vol. 31 (no. 2), pp. 396-404.
Garstang, J., Sidebotham, P. (2018). Qualitative analysis of serious case reviews into unexpected infant deaths
Iwadae, K., Doy, M., Ito, Y. (2001). Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody. Forensic Science International.
Lincolnshire Public Health Intelligence Team. (2018). Evidence Results – SIDS Risk Factors.
Lincolnshire Public Health Intelligence Team. (2018). Evidence Results – Overcrowding, accidents and SIDS.
Lincolnshire Safeguarding Children Partnership. (2018). Sleep Briefing: Sleep positioners, pods and nests.
The Lullaby Trust. (2019). Evidence Base, March 2019.
The Lullaby Trust. Product Guide, a guide to buying safer sleep essentials.
The Lullaby Trust. (2020). Reducing Sudden Infant Deaths in the East Midlands.
Saggiorato, J. (2020). Lincolnshire Child Death Overview Panel (CDOP) Annual Report 2019/20. Lincolnshire Safeguarding Children Partnership (LSCP).
UNICEF. (2019). Co-sleeping and SIDS: A Guide for Health Professionals.