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Safe Sleep for Babies in the Neonatal Intensive Care Unit

​About a half million—or 10% to 15% of U.S. newborns—are admitted to Neonatal Intensive Care Units (NICU) every year for special medical care. Many are preterm and low birth weight infants, who are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly.

Although some infants in the NICU need to be positioned on their stomachs or sides at first, the American Academy of Pediatrics (AAP) recommends transitioning them to a safer sleep position before they are discharged from the hospital.

The AAP provides guidance for healthcare professionals within a clinical report, "Transition to a Safe Home Sleep Environment for the NICU Patient​," as well as a technical report that provides the rationale and protocols for neonatal intensive care units. Both reports are published in the July 2021 Pediatrics.

Starting safe sleep practices before babies go home

"For decades now, we have known that it is safest for infants to sleep on their backs, alone and on a firm mattress with no extra bedding or pillows," said Michael Goodstein, MD, FAAP, lead writer of both reports.

"In the hospital, some infants who are sick or preterm may initially need to be positioned on their stomachs or sides for medical reasons, but they should be switched to a safer sleeping position long before they go home. This decreases the risk of sudden infant death and models a safe sleep environment for new parents."

In the United States, sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), is the leading cause of death for infants between 1 month and 1 year of age. In up to 95% of these cases, there are one or more environmental risk factors identified, according to research.

Studies have shown that neonatal intensive care unit providers do not consistently support infant sleep safety recommendations. Challenges include resolving therapeutic positioning practices for the infant that are consistent with sleep safety at home.

AAP recommendations:

  • The intensive care nursery should develop a safe sleep policy, with the goal of transitioning the infant to a safe sleep home environment consistent with the recommendations of the AAP Task Force on SIDS.

  • The NICU should use an algorithm for routine and repeated evaluation of each infant for safe home sleep readiness. Some safe sleep practices may be added incrementally.

  • All staff involved in the care of NICU infants should receive education on and maintain expertise in infant sleep safety.

  • Family education on safe sleep practices should be provided.

The clinical report also discusses the use of bed positioners, swaddling and thermoregulation regarding sleep-related death, as well as the benefits of human milk and breastfeeding.

Back-to-sleep & beyond

Experts have recommended placing infants on their backs to sleep since 1992 and a Back to Sleep Campaign in 1994 resulted in U.S. SIDS rates decreasing by 53% in 1999.

"We know so much more now about how to prevent tragic deaths due to suffocation or other sleep-related causes," said Rachel Y. Moon, MD, FAAP, chair of the AAP Task Force on SIDS.

"We urge consistent messages to families on how to keep infants safe during sleep, beginning from birth or ideally, even before."

The reports were created by the AAP Committee on Fetus and Newborn and Task Force on Sudden Infant Death Syndrome.

More information

6/21/2021 12:00 AM
American Academy of Pediatrics (Copyright © 2021)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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