1. Beal, Judy A. DNSc, RN, FAAN

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The American Academy of Pediatrics (AAP) first recommended the transition to the supine position for babies by 32 weeks postmenstrual age in 2008 (AAP, 2008), then reaffirmed its message in 2011 (Moon & Task Force on Sudden Infant Death Syndrome, 2016). In 2016, the Academy offered further clarification that all babies, including those who are preterm and low birthweight in the neonatal intensive care unit (NICU) should be placed in the supine position for sleep as soon as they are medically stable, and significantly before their discharge (Moon et al.,). Despite these efforts, some research suggests there is long-term and ongoing nonadherence to this strongly worded recommendation among physicians and nurses in the NICU.


The latest AAP report (Goodstein et al., 2021) provides an in-depth review of literature on the relationship between the clinical issues of respiratory distress, apnea, hyperbilirubinemia, gastroesophageal reflux, and neonatal opioid withdrawal syndrome and how care techniques, specifically nonsupine positioning as well as swaddling and skin-to-skin care, affects infant sleep safety. As the majority of NICU patients commonly require care that is inconsistent with safe sleep recommendations, it is understandable that providers and parents can easily become confused. Preterm and low birthweight infants are two to three times more likely to die from sleep-related deaths, so it is particularly important for NICU providers to develop a standardized and consistent approach to transitioning NICU patients to a safe home sleep environment. In a survey of 96 NICU nurses, 53% strongly agreed that their recommendations make a difference in preventing sudden infant death syndrome, but only 20% strongly agreed that parents would follow through on these recommendations for safe sleep positioning once home (Barsman et al., 2015).


Several standardized programs have been successful and include policies consistent with the AAP recommendations on sleep safety, education for providers and families, visible prompts, modeling of safe sleeping while in the hospital, algorithms for assessment of readiness for safe sleep readiness, and quality improvement audits during hospitalization and postdischarge. The AAP (Goodstein et al., 2021) report provides detailed recommendations for each of the clinical issues discussed, the messages for all conditions are consistent and strong. Although there are commonly used therapeutic interventions used in the treatment of NICU patients that are not consistent with home infant sleep safety, use of these therapeutic interventions should be minimized as much as is medically feasible and when necessary, should be discontinued as soon as possible (Goodstein et al.). Early and frequent education for providers and families, use of crib side visible prompts, and safe sleep modeling are critical. Safe sleep messaging must be clear, consistent, and emphasized well before discharge. Parents must be helped to understand that therapeutic interventions in the NICU are not consistent with sleep safety recommendations and cannot be replicated at home. NICU caregivers' beliefs and knowledge about safe sleep transition may have a significant influence on safe sleep messaging for parents of NICU babies (Goodstein et al.). Nurses play a vital role in sharing this information with parents and role-modeling safe sleep positioning of the baby in the NICU before discharge. Read the AAP (Goodstein et al.) report, discuss with colleagues, and make sure practices in your NICU are consistent with the latest evidence on safe sleep for babies in the NICU and after discharge.




American Academy of Pediatrics Committee on Fetus and Newborn. (2008). Hospital discharge of the high-risk neonate. Pediatrics, 122(5), 1119-1126.[Context Link]


Barsman S. G., Dowling D. A., Damato E. G., Czeck P. (2015). Neonatal nurses' beliefs, knowledge, and practices in relation to sudden infant death syndrome risk-reduction recommendations. Advances in Neonatal Care, 15(3), 209-219.[Context Link]


Goodstein M. H., Stewart D. L., Keels R. L., Moon R. Y.Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome. (2021). Transition to a safe home sleep environment for the NICU patient. Pediatrics, 148(1), e2021052046.[Context Link]


Moon R. Y.Task Force on Sudden Infant Death Syndrome(2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics, 138(5), e20162940.[Context Link]