Sleeping is a necessity of life for your baby. Just as he or she needs nutritious food and plenty of play time, your child also needs safe sleep, for growth and brain development. The best place for an infant to sleep is in his or her own safe sleep environment. Adopting safe sleeping habits reduces the risk of accidents and death: Health Canada reports that while the rate of Sudden Infant Death Syndrome (SIDS) has declined over the years, it remains the leading cause of death of infants 12 months or younger.
CANADIAN INFANT SAFE SLEEP
Establishing a safe sleep environment and good sleep habits are essential to having a healthy baby. Canadian Infant Safe Sleep Project was founded to introduce proven practices and useful resources, in the aim of reducing the risk of unsafe sleep accidents for infants. Let’s take a look at the ABC OF SAFE SLEEP
A – SLEEPING ALONE
The key to safe sleep is a minimalist approach. Never put anything in the crib with your infant. While many crib linen sets come with comforters, bumpers and mattress covers, there should be nothing in the crib with your child. No stuffed animals, no blanket or pillow.
Further, an infant should only sleep on a firm mattress with a tightly fit sheet. Soft surfaces like a couch or an adult bed can pose a danger because a child can smother in the folds of the bedding or soft upholstery. Parents should never bed-share with infants, as they can roll on top of a baby or accidentally push them off the bed. It only takes a hand over a baby’s face for a couple of minutes to smother him or her.
Some hospital policies on bed-sharing present a clear message about the risks associated with it. “Hospitals should not allow mothers to sleep in the same bed with their newborns in view of the effects of postpartum maternal fatigue, analgesia or post-analgesia.”
Risks from bed-sharing include:
- Suffocation (loose bedding, pillows, waterbed)
- Overlay (lying on or against)
- Wedging or entrapment (between mattress and wall, bed frame)
Some other factors that additionally increase the risks of bed-sharing are:
- Impaired bed-sharer
- Obese bed-sharer
- Bed-sharer who smokes
B – BACK IS BEST
Infants don’t know what sleeping position they prefer and can get used to a position simply by the way they are placed in the crib. Caregivers must be consistent about putting an infant to sleep on his or her back: Health Canada reports that putting a child to sleep on his or her tummy increases the risk of SIDS.
The “back to sleep” campaign in the 1990s has been credited for reducing SIDS deaths by 50% worldwide. The research shows that babies that usually sleep on their backs and then are placed on their stomachs to sleep for a nap are at a higher risk for SIDS.
Babies that sleep on their back are also at a lower risk of choking. When baby is on his or her back, their windpipe is on top of the esophagus. Anything regurgitated or refluxed from the esophagus has to go against gravity to be aspirated into the trachea. When baby is sleeping on their stomach and they spit up, the fluids will exit and pool at the opening of the trachea, which increases the chance of choking.
In addition babies have a tonic neck reflex, which causes them to turn their heads to the side when they are placed on their back. If the baby does spit up or vomit, the fluid runs out the nose and mouth, thus avoiding choking
Sleeping on the back is crucial for baby’s safety but tummy time when the baby is awake is critical for the development of large motor skills as well as strengthening the neck and arm muscles, as they try to push themselves up. Tummy times also helps to prevent flat spots on the back of your baby’s head.
Tummy time is when you place your baby on his or her stomach when they are awake and someone is watching them. Tummy time can start once the umbilical cord falls off. Many parents and caregivers find that babies do not like tummy time, so be sure to start off with short sessions, two to three times a day. As your baby gets older, your sessions can last longer and you can have more of them during the day. They must alway be supervised: do not leave your child alone during tummy time.
C – CRIB IS THE SAFEST PLACE TO SLEEP
The safest place for a child to sleep is by his or herself in a Health Canada approved crib, bassinet or cradle. All approved cribs must have a sticker that is found directly on the product: it details manufacturer name, model, serial number and date of manufacture.
In addition, the crib should be in good condition and have a firm mattress. NEVER modify a crib and always follow manufacturers assembly / usage instructions. If a you are buying or receive a used crib, check the label to see what date it was manufactured: cribs made before 1986 should not be used.
It’s a good idea to do a product safety search on the Internet, to check to see if the crib has been the subject of a recall. Safety standards have become more rigorous over the past two decades. For example, drop side cribs are no longer manufactured or sold in Canada because of the risk of the side collapsing and trapping the child. A quick Internet search should result in consumer reviews or any government warnings about the crib or bassinet purchased.
All cribs should be adjusted as the child grows. Once the child can stand, the mattress height should be moved to the lowest setting so that the child cannot climb out. One of the most common child accidents is when children climb out of a crib and fall to the ground. Health Canada recommends parents stop using a crib and transition a child to a toddler bed once the child is able to pull themselves out of the crib.
The crib should contain only a tight fitted sheet on a firm mattress. No blankets, pillows or stuffed animals. Loose bedding and other items that are put either over or under baby could end up covering the baby’s face, which can put the baby at a higher risk of suffocation or strangulation. It could also cause the child to re-breathe air that is low in oxygen and high in carbon dioxide. Do not cover baby’s head with a hat for the same reasons. Do not use bumper pads or positioners of any sort.
Remember SUN: Simple, Uncluttered, Nothing but the baby.
Do not let your baby get too hot during sleep. Babies that get too warm while they sleep may sleep too deeply and may not be able to wake themselves up. You can check to see if your baby is too hot by looking to see if they have red cheeks and feeling if the back of their neck is sweaty. They may also breathe rapidly. Don’t rely on the temperature of their hands or feet, as this can be misleading.
In the summer months a child can sleep in a single layer or in a T-shirt and diaper. In the winter, the child might be comfortable in pyjamas and wearable blankets such as the Halo SleepSack®.
If your child wakes up a night and her skin is cold to the touch, another layer could be added. Your child only needs as much clothing as a parent wears to sleep so be careful not to over dress them.
KEEPING A CHILD WARM WITHOUT A BLANKET
If you feel that baby is cold and needs an extra layer, it is recommended by the Ontario Nurse Association to use a proper fitting wearable blanket. Never put a loose blanket in the crib.
More and more hospitals in Canada (30) and in the USA (over 1000) use wearable blankets in their maternity wards to set a good example and to educate parents from day one.
While pillows, bumpers are a pretty crib decoration, they are also a hazard as your child can smother him or herself if he or she puts their face against the material-lined crib railings. Just because it is for sale does not mean that it is safe. A 2009 study conducted by Dr. Rachel Moon at the Children’s National Medical Centre found that in magazines targeting women of childbearing age, more than one third showed babies in unsafe sleep positions and more than two thirds showed babies in unsafe sleep environments.
Children can suffocate if their faces are covered because they don’t yet know how to turn their face or move the covering. The safest practice is to only allow a blanket for sleep once your child is in a toddler bed.
CAR SEAT SLEEPING
As of late, there have been increasing numbers of media reports about children dying while sleeping in a car seat. An infant’s head slumps forward naturally when they fall asleep in a car seat, creating the risk of suffocation by an obstructed airway.
A child should never be left unattended while sleeping in a car seat nor should a car seat become a substitute for a crib. If your child falls asleep in the car, place her in a safe sleeping environment as soon as you arrive at your destination.
When caregivers are hired or relatives volunteer to care for an infant, a parent must instruct them on the safe sleeping principles. Provide a written guide for reference to ensure they don’t forget.
Caregivers must be especially mindful of the proper sleep position regardless of their personal views. Many caregivers and grandparents have their own ideas of how to put a child to sleep. Take the time to give the caregiver a tour of your home and instruct them on the proper technique of back sleeping, what the infant should wear and how to put the baby to bed safely. Have pajamas and wearable blanket ready and be sure to specifically tell caregivers not to add extra layers.
Make sure before leaving your baby with anyone that they know about safe sleep. One nap is all it takes for things to go badly wrong.
BREASTFEEDING AND BED-SHARING
While bed-sharing is reported to increase the duration and frequency of breast feeding and augment the opportunity for bonding, the benefits are outweighed by the risks attributed to bed-sharing. The OCC and the Ontario Association of Children’s Aid Societies (OACAS) support breast feeding but recommend bonding while awake and never sharing a sleep surface with an infant.
What have we learned?
SIDS VERSUS SUDI
To talk more about the risks and the importance of safe sleep environment, we need to understand the difference between SIDS (Sudden Infant Death Syndrome) and SUDI (Sudden Unexplained Death in Infancy).
SIDS – Sudden unexplained death of an infant under 1 year of age, which remains unexplained after: complete autopsy, scene investigation and a review of social and medical history
SUDI – Sudden unexplained death of an infant under 1 year of age, which remains unexplained after: complete autopsy, scene investigation, review of social and medical history where risk factors are identified, which may or may not be causal/contributory
The Office of the Chief Coroner for the Province of Ontario defines SIDS as NATURAL and SUDI as UNDETERMINED and notes bed sharing is at the top of the list of common themes in paediatric deaths. Enhancing awareness of unsafe sleep environments results in decreasing numbers of SIDS and increasing in the numbers of SUDI classifications. In an OCC study on unsafe sleep in 2003- 2007, 80% of deaths occurred in unsafe sleeping environment, with the leading cause as bed-sharing (65%). In 165 infant deaths in Ontario (Coroner), approximately 50 (30%) of infant deaths each year in Ontario are SUDI. The majority of these involve unsafe sleep environments / habits, including at least 25-30 infants who bed-shared with caregivers.
With a growing body of evidence to substantiate their position, Health Canada reminds parents and caregivers that the safest place for an unsupervised baby to sleep is alone in a crib. Babies and young children should never be placed to sleep in products that are not specifically designed to accommodate an unattended sleeping baby, such as car seats, strollers and change tables.
Public Health Agency Canada’s New Safe Sleep Brochure available here.
Babies always need a safe sleep place. SIDS and SUDI are different. Too many babies are dying in unsafe sleep environments – these deaths are preventable! A growing body of evidence supports the risk of bed-sharing outweigh the benefits.
A SAFE SLEEP ENVIRONMENT IS CRITICAL TO INFANT SAFETY/RISK ASSESSMENT
Parents whose babies have died want other parents to know:
- Babies are not safe sleeping on a couch, pillow or anything soft.
- Babies are not safe sleeping with other children, adults or pets.
- Babies are not safe sleeping in adult beds.
- If you feed your baby in bed, put your baby back into his or her crib to sleep.
SAFE SLEEP ABC: Alone on Back in an approved clutter-free Crib