Infant Safe Sleep Presentation delivered at Prevent Child Abuse Iowa Strengthening Families, Building Hope Conference, May 2, 2017.

1. Say YES to
Safe Sleep for
Babies

2. Definitions
○ SUID = Sudden and Unexpected Infant
Death.
○ Aka Sudden and Unexpected Death in
Infancy (SUDI)

3. Sleep-Related Deaths
○ Most SUIDs occur during sleep or in sleep
environment = Sleep-related deaths
○ Suffocation, strangulation, entrapment
○ Undetermined/ill-defined/unknown
○ SIDS

4. Sleep-Related Deaths
Any SUID (i.e. sudden and unexpected death) that
remains unexplained after:
○ A complete review of the history
○ An autopsy
○ A death scene investigation
Typically, a seemingly healthy infant is found dead
after a sleep period, dying either during sleep itself
or during a transition from sleep to waking.
○ A diagnosis of exclusion
○ SIDS is not predictable

5. Triple Risk Model
Brainstem
dysfunction,
Arousal defect
Gene
polymorphism
Highest risk at 2-4
months
Prone sleep position, smoke
exposure, soft bedding

6. Behavioral,
Sociocultural,
and Environmental
Factors
Genetic
Factors
Phenotype
SIDS

7. Our current hypothesis is that SIDS
results when a vulnerable infant
cannot adequately defend against an
asphyxiating environment — a level
of asphyxia where most infants would
not die.
SIDS

8. Rebreathing Theory
○ Infants in certain sleep environments are
more likely to trap exhaled CO2 around
the face
● Lie prone and near-face-down/face-down
● Soft bedding
● Tobacco smoke exposure
○ Infants rebreathe exhaled CO2
○ Infants die if they cannot arouse/
respond appropriately

9. Infant Vulnerability and Positional
Asphyxia
Maternal
smoking and
alcohol
Brainstem dysfunction
Prematurity
Severe
Vulnerability
Normal
Infant
Infant
High
Critical period of
development
CLEAR
EVIDENCE FOR
ACCIDENTAL
SUFFOCATION
Non
Asphyxiating
Severe
Asphyxiating
Sleep Environment
COMBINATIONS OF SIDS RISK FACTORS
Prone sleep, soft bedding, over-bundling, head
covered, bed sharing
Chronic hypoxia
Strangulation
Entrapment
Overlaying
A safe sleep environment can reduce the incidence
of both SIDS and Accidental Suffocation
Adapted from Randall BB, et al. Forensic
Sci Med Pathol, 5:254-260, 2009
Shading indicates the
probability of death.
Darker shades = increased
probability of death.
Interactions can occur anywhere
along the continuum
Accidental
Suffocation
SIDS
The position of the threshold between a diagnosis of SIDS or
Accidental Suffocation is determined by the medical examiner
based on history and death scene investigation.
SIDS? SIDS?
Undetermined?
Cause of
death?

10. 0
10
20
30
40
50
60
70
80
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Percent back sleeping
SIDSrate
Year
SIDS Rate and Infant Sleep Position,
1988-2010
(Deaths per 100,000 live births)

11. However…
Increasing rates of other sleep-related
deaths:
○ Accidental suffocation
○ Entrapment
○ Undetermined
○ Most (80->90%) of these occur in unsafe
sleep environments
● Bedding
● Bed sharing with others

12. Rates of SIDS and SUID
Source: CDC Wonder, 2013
0
20
40
60
80
100
120
Deaths/100,000LiveBirths
Year
Proportion of Sleep-Related Deaths, US: 1995-2009
ASSB
Ill-defined
SIDS

13. ASSB rates per 100000 live births,
United States, 1984-2004
Shapiro-Mendoza, C. K. et al. Pediatrics 2009;123:533-539
Copyright ©2009 American Academy of Pediatrics

14. Why is SUID increasing?
○ Diagnostic shift
● Improved death scene investigation
● Deaths previously called SIDS now called something else
○ Increases in prone sleeping
○ Increases in soft bedding use
○ Increases in bed sharing (particularly with multiple people,
bedding, etc.)
○ 80->90% of sleep-related deaths occur in unsafe sleep
environments
● Bedsharing
● Bedding

15. What’s the problem?
○ Everybody thinks that his/her baby is the
exception to the rule
● Gastroesophageal reflux
● Premature
● “Bad” sleeper
○ OR the rules don’t apply to their
particular situation
● “This only happens to other people”
● “I pay close attention to my baby”

16. Why should I care?
○ I’m just a doctor (nurse, social worker,
nutritionist, your position)
○ Nobody listens to me
○ Why should I care?

17. The influence of health care professionals
○ Parental report (Smith, 2010):
● 54% receive no advice about infant sleep location/
bedsharing
● 73% receive no advice about pacifier use
● 28% receive no advice about safe sleep position
○ More likely to use safe sleep practices if
counselled by physician
○ More than 90% of parents follow sleep
recommendations from MD/RN
○ 93% of parents who see infant placed prone
by hospital personnel use prone (Brenner, 1998)

18. Current Recommendations
American Academy of Pediatrics (AAP)
○ Back to sleep for every sleep
● Preterm infants by 32 weeks post-menstrual age
● Infants in newborn nursery
○ Use a firm sleep surface
● No pillows, quilts, adult beds
● No sitting devices
○ Roomsharing without bedsharing is recommended
○ Keep soft objects and loose bedding out of the crib
● Pillows, quilts, sheepskins, blankets, bumper pads
○ Pregnant women should receive regular prenatal care

19. Current Recommendations
American Academy of Pediatrics (AAP)
○ Avoid smoke exposure during pregnancy and after birth
○ Avoid alcohol and illicit drug use during preganancy and after
birth
○ Breastfeeding is recommended
○ Consider offering a pacifier at naptime and bedtime
○ Avoid overheating
○ Immunize infants
○ Avoid commercial devices marketed to reduce the risk of SIDS
○ Supervised, awake tummy time is recommended

20. ABCs of Safe Sleep
Baby ALWAYS sleeps:
A. ALONE
B. On their BACK
C. In a safe CRIB or bassinet nearby

22. Say Yes to Safe Sleep PSA (2015)

23. Infant Safe Sleep
What does it look like?
23

24. Safe Places for Baby to Sleep

25. Inflatable
mattresses
Car seat or
carrier
Sofa or couch Chair
Bouncy chair or
swing
UNSAFE Places for Baby to Sleep

26. UNSAFE Places for Baby to Sleep
26

27. Swings, car seats, bouncy seats?
Should not be used for sleeping
○ If a baby falls asleep, he or she should be removed
and placed in a safe crib as soon as it is practical

28. How parents/caretakers can
arrange the room for safety

29. Bed Sharing
(also known as co-sleeping)

33. Room Sharing
Infant sleeps near the parent or caregivers in
their own crib, bassinet or portable crib.

34. THE COMPETITION WE’RE UP AGAINST

35. Frequently asked questions
AKA
Questions that
parents ask that
you’re afraid to
answer

36. My mother told me to never put my
baby on her back to sleep, because
she can choke and die. So my baby
sleeps on her stomach.
Choking/aspiration

37. Choking/aspiration
○ No increased risk of aspiration with supine sleeping,
even if baby has reflux
● Infants with GER should also be placed supine
● Gag reflex
○ Exception: so severe that risk of death from GER is
higher than risk of SIDS
○ Parents often don’t believe this because this seems
counterintuitive
○ Drawing a picture of the anatomy is often helpful

40. I’m hearing different things about
swaddling babies. Should I not
swaddle my baby, or is it okay to
swaddle?
Swaddling?

41. Swaddling
Pros:
● Calms the infant; promotes
sleep; decreases number of
awakenings
● Encourages use of the supine
position
Cons:
● Increased respiratory rate and
reduced functional residual lung
capacity
● Exacerbates hip dysplasia if the
hips are kept in extension and
adduction
● “Loose” swaddling becomes
loose bedding
● Overheating, esp if the head is
covered or the infant has
infection
● Effects on arousability to an
external stimulus remain unclear
(conflicting data). There may be
minimal effects of routine
swaddling on arousal.
● 12x risk of SIDS if swaddled and
not supine

42. Swaddling
There is insufficient evidence to
recommend routine swaddling as a
strategy to reduce the incidence of SIDS.
If babies are swaddled, they should
always be on the back
When the infant shows signs to trying to
roll, swaddling should not longer be
used.
Swaddling does not reduce the
necessity to follow recommended safe
sleep practices.

43. I am breastfeeding my baby.
Everyone has been telling me that
it’s safe to bedshare since I’m
breastfeeding. Is that true?
Bedsharing and breastfeeding?

44. Problems with bedsharing
○ Overheating
○ Soft bedding
○ No safety standards for adult mattresses
o No study has ever shown a protective effect of bed sharing on SIDS
o Risk of entrapment, accidental suffocation and strangulation
(CPSC)
o Predominant risk factor for sleep-related deaths in infants <4
months (Colvin, 2014)
o Most studies on bed sharing have only looked at SIDS, not other
deaths

45. But is a breastfeeding mother a
special case?
○ Breastfeeding mothers are
generally low risk
● Older, higher SES, more educated
● Non smokers
● Do not drink alcohol as much
● Do not usually use drugs (illicit and legal)
o Breastfeeding confers protection against SIDS
• Doesn’t that cancel out the risk of bedsharing?

46. Breastfeeding and bedsharing
In Ostfeld’s study, 25% of bedsharing deaths
were breastfed (exclusively and partially
breastfed) infants
○ Younger (median 45 vs 97 days of life)
○ More bedding risks (64.7% vs. 45.1%)
○ Less likely to be prone (11.8% vs 52.9%)
○ Less likely to be exposed to maternal
smoking (33% vs 66%)
-Ostfeld et al, Pediatrics, 2006

47. How can we make bedsharing safer for the
breastfeeding mother (and other mothers)?
○ No large-scale, epidemiologic data for breastfeeding
mothers
○ Breastfeeding does not cancel out the risk of
bedsharing
○ Still a risk, particularly for those <4 months of age
○ No data about what makes bedsharing safer
○ Sleeping with the baby on a separate surface next to
you is the safest
○ Recommendations for making bedsharing safer are
extrapolated from solitary sleeping infants
○ We don’t know if they pertain here

48. Ways to potentially, maybe make
bedsharing safer…
○ Use a firm, flat mattress without mattress topper or
memory foam.
● No waterbeds, air mattresses, couches, or armchairs
● No pillows, comforters and other soft bedding
○ Ensure that the baby’s head and face are not covered.
○ Do not use pillows or other soft objects to try to prevent
the infant from falling out of bed or getting caught
between the mattress and headboard or footboard.
○ Do not cover the infant with loose bedding.
● An alternative is to use infant sleep clothing such as a wearable
blanket.
○ Place the infant on the back for sleep.
○ Bed sharing should be with mother or parents only.
○ It is safer to breastfeed in bed than to move the infant to a
sofa or armchair to feed.

49. We like to snuggle with the baby
after we come home from work on
the couch. Is that okay?
Sofa Sharing

50. NO!
○ The couch or sofa is probably one of the most
dangerous places for a baby to sleep, with or
without the parent (OR 5.1-66.9).
○ Do not lie down on a couch with a baby or feed a
baby on the couch, sofa, or other heavily cushioned
chair, if there is a chance that you may fall asleep
with the baby.
○ It is less dangerous to feed the baby in bed than on
a sofa or armchair.

51. My child care provider
told me that she always
puts babies on their
stomachs because they
sleep better that way.
Can you sign this paper
so that she can put my
baby on the stomach?
But the baby sleeps better…

52. Is it really BETTER?
○ #2 reason for babies being placed prone
○ Babies prone have higher arousal
thresholds, sleep longer and deeper
○ This increased arousal threshold may be
dangerous, as arousal may be the issue
surrounding SIDS…
○ Need to change definition of a “good”
sleeper

53. What about the baby boxes from
Finland?
Baby Boxes?

54. Baby Boxes
Modeled after “Finnish Baby Box”
Available for parents in Alabama, New Jersey and Ohio
Some Concerns
○ Potential suffocation hazard if the baby rolls into the
side of the box.
○ Placing baby on the floor may cause a tripping hazard
posing a danger of someone falling on top of the baby.
○ Pets can easily get into the box and rodents and
roaches are attracted to cardboard.
○ Parents may decide to place the box on an unstable
surface such as a dresser, counter or couch.
○ There are no Consumer Product Safety Commission
(CSPC) Guidelines for Baby Boxes because they don’t
meet definition of a crib, bassinet, play yard or
handheld carrier.

55. The American Academy of Pediatric Task Force
on SIDS does not believe that there is yet
enough evidence to say anything about the
potential benefits or dangers of using baby
boxes, wahakuras, or pepi-pods. In reference
to Finland, researchers have never studied the
baby box there, and although their infant
mortality rate is lower than some other
industrialized countries, there are many other
reasons for their low infant mortality rates.
AAP Statement on Baby Boxes

56. If we want to continue making
progress
We need to understand
why the community is
not embracing safe sleep
recommendations:
○ Perceived barriers/cost
○ Misconceptions
○ It doesn’t make sense to
them
○ It’s not important to
them
We need to make sure
that our message:
○ Makes sense
○ Is consistent
○ Explains the
advantages
○ Addresses
misconceptions

57. Your Important Role
You can impact on the number of SUID
deaths that are occurring
○ Consistent messaging
○ Consistent modeling
You can definitely make a difference

58. It helps if the message is consistent
Health care professionals
“When I was in the hospital, the nurse put my baby on her stomach…
if it’s so important, how come the nurse isn’t doing it?”
Media
If I’m not hearing about it, it must not be a problem anymore
Advertisers
If the stores are selling it, it must be safe

59. Why parents may not embrace
your words
Risky behaviors may be perceived as being important
practices (culture, tradition, safety)
○ Bedsharing
○ Prone sleeping to avoid aspiration
Risky behaviors may be important coping mechanisms
○ Smoking
○ Alcohol use
Risky behaviors may be unavoidable
○ No money to purchase a crib
Very little perception of risk from SIDS

60. Every parent wants two things…
Every parent wants his/her baby to be
○ Safe
○ Happy
You are only as happy as your least happy
child
Your message needs to be consistent with
these 2 goals

61. It’s a SALES JOB…
○ Roomsharing without bedsharing
● Crib next to parents’ bed
● Can be vigilant and keep eye on baby, but don’t have to worry
about pillows and blankets that are in your bed
● Don’t have to worry about baby falling off
○ Pacifier: helps to soothe the baby
○ Know what the perceived disadvantages are and be
able to explain why they’re not problems

63. West Virginia
Say YES to Safe
Sleep Hospital Based
Pilot Project

65. Hospital & Community-Based
Importance
• Reach parents early
• Nurses are important role models
– More than 90% of parents follow sleep
recommendaJons from MD/RN
– 93% of parents who see infant placed prone by
hospital personnel use prone (Brenner, 1998)
• Home Visitors also viewed as important role models
• Cost-effecJveness
• PrevenJon is part of quality
65

66. WV Pilot Design
○ Based on York Hospital in PA
○ Replicated in BalJmore and East Tennessee
○ Modeled aer AHT Program/Period of PURPLE Crying
Program®/Dias Model
○ Three Doses
• Hospital
• Home Visitors / Office Visits
• Public Awareness
66

67. Say YES to Safe Sleep for Babies
Uses trained educators to deliver and reinforce
consistent messages in different environments
○ Initial education: prenatally, in-hospital prior to
discharge, or postpartum if not received in the
hospital
○ Reinforcement education: post-partum, such as
through home visits, childcare settings, office visits,
etc.
○ Community education: media outreach events, crib
displays, mother-baby showers, health fairs, infant
safe sleep month activities, PSAs, social media

68. Say YES to Safe Sleep for Babies
Target Audiences:
○ expectant parents
○ parents of infants under age of one
○ other caregivers of infants under age of one
○ general public (through the media)

69. Say YES to Safe Sleep for Babies Partners
○ WV Birthing Hospitals
○ WV Home Visitation Programs
○ Other medical and health care professionals
○ Early childhood professionals and social
service providers
○ Community-based organizations

70. A Word About Readiness
There are a few key steps that organizations should take
before delivering the Say YES program and getting free
materials:
1. Establish a champion or team of champions
2. Ensure all staff are trained
3. Develop a safe sleep policy or standards of care,
including an audit or assessment process to track
adherence and fidelity
4. Share your written safe sleep policy or standards of
care with all relevant staff

71. Guide and Toolkit
Organized into separate
documents
○ Background
○ Initiative Summary
○ Readiness steps/checklist
○ Readiness to Action
○ Implementation Phase
○ Resources and
Supplemental Materials
www.safesoundbabies.com

72. Say YES Parent/Caregiver
Educational Materials
Materials & tools have been designed to be:
○ Attractive & user-friendly with an emphasis
on positive messages
○ Based on American Academy of Pediatrics
Guidelines
○ All materials are FREE and can be ordered
online or downloaded at
www.safesoundbabies.com

73. Say YES Parent/Caregiver
Educational Materials
Parent/Caregiver Educational Kit
○ Say YES To Safe Sleep For Babies brochure
○ Say YES parent DVD
○ Say YES pledge card
○ Click pen with messages
○ Keep Your Cool When Baby Cries brochures
(Mom and Male Caregiver versions)

74. Say YES Parent/Caregiver
Educational Materials
Additional materials
○ Say YES and Keep Your Cool Posters
○ Say YES and Keep Your Cool Public Service
Announcements
○ Sleep Baby, Safe and Snug book (Charlie’s
Kids Foundation)
○ Say YES Grandparent brochure and poster

78. Say Yes to Safe Sleep PSA (2015)

79. Say YES to Safe Sleep Pledge Card

80. Say YES to Safe Sleep DVD

81. Sleep Baby Safe and Snug Children’s Book

82. Say YES to Safe Sleep Messages
○ ABCs: Babies should sleep alone, on their
back at every bedtime & naptime and in a
crib nearby, (bassinet or portable crib) Do
not place babies to sleep on adult beds,
chairs, sofas, waterbeds, or cushions – this
increases the risk of accidental suffocation.
○ Room share – do not bed share: Put your
baby’s bed near where you sleep – within
arm’s reach – easier to breastfeed and bond
with baby.

83. Say YES to Safe Sleep Messages
○ Babies should not sleep with anyone else,
including pets or other siblings.
○ Babies should sleep in a smoke-free area.
○ Babies should be dressed in light sleep clothing
and the room temperature should be
comfortable – not too hot.
○ There should be no bumper pads, stuffed
animals, toys, or heavy or loose blankets in the
crib.

84. Say YES to Safe Sleep Messages
○ The crib should be in good condition and
safe (no drop-down side cribs):
www.cpsc.gov
○ Breastfeed your baby.
○ Tell others: Say YES to Safe Sleep!

85. Delivering the Messages
Prenatal or Before Discharge from Hospital
1. Review materials one-on-one with parents or
caretakers by watching the DVD & reviewing
brochure using provided teaching points.
2. Answer any questions.
3. Confirm there is a safe place for the baby to sleep.
4. Encourage parents to share materials with others.
5. Ask parent to sign voluntary sleep pledge promising
safe sleep practices for the baby.

86. Delivering the Messages
○ Emphasize the reason behind the
messaging.
○ Use an open dialog approach.
○ Be culturally sensitive – No Judgment
Zone.
○ Answer questions.

87. Delivering the Messages
○ Model correct safe sleep practices every time
you put a baby down to sleep.
○ Make a point to tell parents and caregivers why
you are putting their baby to sleep this way.
○ If you find the baby sleeping in an unsafe
position, correct the situation and use it as a
teachable moment.
○ Reference your safe sleep policy.

88. Additional Ways to Deliver Messages
and Change Organizational Culture
○ Keep items such as charts, loose blankets, etc. out of nursery
bassinets.
○ Display posters at appropriate locations + use other visuals.
○ Add messages to call-waiting/use screen savers.
○ Show the Say YES to Safe Sleep DVD via closed circuit TVs in
waiting rooms, hospital rooms, community events, etc.
○ Set up a model nursery/safe sleep center with materials.
○ Continue to model safe sleep practices!

89. Keys to Success
Consistent
Messaging
Consistent
Modeling
Safe Babies
&
Fewer
Deaths
Parents and caregivers:
• Hear same message
from all providers
• Hear message multiple
times
• Hear message in
multiple ways
• Put babies to sleep in
the safest position
• Find “teachable
moments” to correct
unsafe behaviors
All together:
• We will save babies
lives!

90. Delivering Reinforcment Messaging
If parents did not receive initial education
either prenatally or in the hospital, you will
need to provide initial education materials
(parent educational kit) and ABC messaging
first, followed by reinforcement education
later
5/2/17! 90

91. Delivering Reinforcment Messaging
○ Ask where the baby sleeps
○ Observe the environment and practices
○ Offer nonjudgmental guidance to correct
any unsafe practices
5/2/17! 91

92. Additional Tip
Engage parents in face-to-face discussion
and use “teach back” versus just handing
the materials to families.
5/2/17! 92

93. Community Outreach Strategies
○ Display posters at
appropriate locations
+ use other visuals
○ Show the Say YES to
Safe Sleep DVD and
PSAs
○ Set up a model
nursery/safe sleep
center with materials

94. Community Outreach Strategies
○ Host community baby showers
○ Link with other community
partners on outreach events
○ Address mixed messages and
visuals in the media
○ Use social media tools to
promote infant safe sleep

95. For the Say YES Guide and
Toolkit and to order free
materials visit:
www.safesoundbabies.com

96. National Web Resources
○ Cribs for Kids: www.cribsforkids.org
○ Eunice Kennedy Shriver National Institute for Child
Health and Human Development
www.nichd.nih.gov/SIDS/
○ First Candle www.firstcandle.org
○ National Center for SUIDS/SIDS www.sidscenter.org
○ Healthy Childcare America/AAP
www.healthychild.org
96

97. Thank You!

98. Jim McKay
Our Babies: Safe & Sound
Jim@TEAMWV.org
304.617.0099
www.safesoundbabies.org
Slides available at:
http://www.slideshare.net/pcawv
Contact Information