Safe Sleeping Concerns for NICU Healthcare Professionals

Myra Rolfes, MN BSN RNC-NIC
Staff Nurse Leader, NICU
Children’s Healthcare of Atlanta at Egleston, Atlanta, GA

Starting in 1994, the American Academy of Pediatrics’ Back to Sleep campaign reduced the incidence of sudden infant death syndrome (SIDS) in the United States by more than 50% (Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2013). An evolving understanding of sudden unexplained infant death (SUID) has led to the identification of three main categories of death in infancy: SIDS, in which no known explanation for death can be found even after a thorough clinical history, death scene investigation, and autopsy; accidental suffocation or strangulation in bed (ASSB); and an "unknown" category for deaths with factors that do not meet the criteria for SIDS. An increased understanding of the importance of the sleep environment led to the updated Safe to Sleep campaign in 2012. Despite these extensive educational efforts, sleep-related deaths remain a leading cause of infant mortality in our country, higher than shaken baby syndrome and motor vehicle injuries.

Neonatal healthcare providers in particular should be concerned about the issue of safe sleeping because preterm infants are at an increased risk for unexplained infant death and studies have shown that very low birth weight infants are more likely to be placed in a non-supine position for sleep after discharge. The importance of modeling safe sleep practices in the neonatal intensive care unit (NICU) also has been shown to influence parent behaviors at home.

It also is important for NICU caregivers to understand safe sleep legislation and resources. Many states have laws governing death scene investigation and data gathering. In December 2014 federal legislation was enacted: The Sudden Unexpected Death Data Enhancement and Awareness Act, which charges the Centers for Disease Control and Prevention (CDC) to collaborate with state and local agencies to improve the quality of data collection and reporting.

Arizona, California, Colorado, Florida, Illinois, Indiana, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, Ohio, Tennessee, Texas, Washington, West Virginia, and Wisconsin require adherence to safe sleeping standards and mandated safe sleep education for child care providers. If your state is not included, advocating for such standards is important, as one in five sleep-related deaths occurs when the infant is in the care of someone other than a parent.

More recently, California, Connecticut, Florida, Illinois, Michigan, New Jersey, Ohio, Pennsylvania, Tennessee, Texas, and Virginia have enacted requirements that all birthing centers and hospitals provide safe sleeping education to new parents prior to discharge. Alabama, Alaska, Delaware, Georgia, Indiana, Nebraska, New York, North Carolina, and West Virginia have initiatives providing resources and encouraging similar education by birthing hospitals and organizations.

Another concerning development in the safe sleep conversation is the turn toward criminal charges for adults who are intoxicated and elect to sleep with an infant who then suffocates. Although the possibility of making “intoxicated co-sleeping” a crime has been proposed, some states have charged adults involved with negligent or reckless homicide. Cases in Georgia, Illinois, Minnesota, and Wisconsin have increased the discussion of this issue, which remains a controversial topic. It often can be difficult to assess the person's level of intoxication at the time the adult falls asleep with the child because it may be hours later when the adult awakens to discover the tragedy. The role of co-sleeping in infant death is significant, and alcohol increases the danger. These facts must be included in education for parents.

Regardless of whether your state requires that you provide safe sleep education for your NICU parents or has developed an initiative that will help you with resources, you can be instrumental in modeling and providing safe sleep education that could be life saving for your patients. Your advocacy can begin at the bedside and extend to your organization and beyond! Be sure that your organization has a safe sleep policy. Check your state public health website for resources. Other websites that provide handouts and information for parents and professionals include

The Centers for Disease Control 

The Eunice Shriver National Institute of Child Health and Human Development

Healthychldren.org, from the American Academy of Pediatrics

The National Action Partnership to Promote Safe Sleep (NAPPSS), funded by the U.S. Maternal and Child Health Bureau


Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2013). Sudden infant death syndrome (SIDS): overview. Retrieved from https://www.nichd.nih.gov/health/topics/sids/Pages/default.aspx

Gelfer, P., Cameron, R., Masters, K., & Kennedy, K. A. (2013). Integrating “back to sleep” recommendations into neonatal ICU practice. Pediatrics, 131(4), e1264–1270.

Kittle, M. D. (2013, September 27). Deadly rest: Bill goes after fatal intoxicated co-sleeping. WisconsinWatchdog.org. Retrieved from www.watchdog.org/107888/deadly-rest-bill-goes-after-fatal-intoxicated-co-sleeping/

National Association of Neonatal Nurses. (2016). Fact sheet on safe sleep. http://nann.org/uploads/Advocacy_Fact_Sheets/2016_Safe_Sleep.pdf

National Conference of State Legislatures. Sudden unexpected infant death legislation. Retrieved from http://www.ncsl.org/research/health/sudden-infant-death-syndrome-laws.aspx

Wellner, B. (2014, August 5). 'Co-sleeping' blamed in infant son's death; parents charged. Quad-City Times. Retrieved from http://qctimes.com/news/local/crime-and-courts/co-sleeping-blamed-in-infant-son-s-death-parents-charged/article_59bba700-aa22-5c44-a411-4c71457ed943.html

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