# Presentation: 560041

## Implementing the AAP SIDS Prevention Guidelines During Discharge Planning In The NICU

**Jennifer Sedlmeyer, BSN, RN**
**Inova Fairfax Hospital Director of Perinatal Outreach**

## The Catalyst

- Two years ago, physicians discharging patients from the Inova Fairfax Hospital For Children NICU identified that infants in the NICU who had grown to term corrected gestational age (CGA) were not following the AAP’s recommendations for infant sleep.
- At the time of discharge parents were asking inappropriate questions such as, “Where can I purchase a gel pillow for my baby to use at home?” and “How should I prop up the head of the crib at home?”

## The Catalyst

- At the same time, a baby who went home from the NICU was placed on his abdomen to sleep and died of SIDS.
- Mom stated “Even though the written instructions said to place the baby on his back to sleep, I placed the baby how the nurses had placed him, on his tummy”.

## Taking Action

- A literature review of the current guidelines for infant sleep was conducted, focusing on premature infants nearing term GCA.
- Experts in the field of SIDS were contacted to discuss the AAP recommendations and how they pertain to infants born prematurely.
- The most current recommendations and research were compiled into a report.

## The Task Force

- Staff members volunteered for a SIDS Prevention Task Force that developed NICU sleeping guidelines based on the current recommendations, personal experience, standards for supporting developmentally appropriate care, and the opinions of experts in the field.
- The task force also developed a parent handout to explain the transition process for preterm infants as they grow closer and closer to term CGA.

## Results

- Practices in the NICU significantly improved in safety.
- Surveys of NICU Staff found the guidelines to be helpful and user-friendly.
- A survey of the NICU Parents showed an increase in knowledge and in satisfaction with care.

- 		THE LITERATURE REVIEW

## Historical Perspective

- “And this child died in the night; because she over laid it.” 1Kings 3:19-20
- In 1291 a German poster forbid mothers from taking their infants under 3 years of age to bed with them.
- Late 1800’s SIDS was first defined “Sudden and Unexplained Death in Children”

**Notes:**
Reports of infants dying suddenly during periods of sleep are mentioned in ancient Greek, Latin and Egyptian literature, as well as in the bible. However, SIDS was not defined as a diagnosis until the late 1800’s.

## Definition of SIDS

- The sudden death of an infant under 1 year of age, which remains unexplained after
- Thorough case investigation
- Complete autopsy
- Death scene investigation
- Review of the clinical history

**Notes:**
The National Institute of Child Health and Human Development has defined SIDS as the sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene and a review of the clinical history.

Since SIDS is basically a diagnosis of exclusion, it is important that a thorough investigation is conducted to make sure there is not another cause of death.

## Facts About SIDS

- SIDS is the 3rd leading cause of death in infants under 12 months of age.
- 91% of SIDS deaths occur before 6 months of age.
- The peak is between 2-4 months of age.
- African American infants are nearly 2 1⁄2 times more likely to die of SIDS than white infants.

**Notes:**
SIDS is the 3rd leading cause of death in infants under 12 months of age (after congenital anomalies and VLBW r/t prematurity).
91% of SIDS deaths occur before 6 months of age.
The highest risk for the occurrence of SIDS is between 2-4 months of age.
African American infants are nearly 2 1⁄2 times more likely to die of SIDS than white infants.
AA are also 2X as likely to place their babies in the prone position for sleep.  

## Facts About SIDS

- SIDS is ***not***
- Caused by vomiting and choking
- Caused by immunization
- Contagious
- The result of neglect or child abuse
- Hereditary
- Predictable or preventable

**Notes:**
SIDS is not caused by vomiting or choking. 
It is not caused by immunizations. However most children get their first set of shots at 2 and 4 months and, as I just stated, this is the highest risk period for SIDS. 
SIDS is not cause by child abuse. 
It is not contagious or inherited (Although an infant may have a inherited metabolic disorder which can be fatal and at times is mistaken for SIDS).
At this time we cannot predict which babies will die from SIDS, nor can we prevent SIDS completely. However, we know that there are some common characteristics and risk factors for SIDS babies and that some of these risk factors can be eliminated by simply changing a few things.

## Which Babies Are at Greatest Risk?

- Infants of mothers with late/no prenatal care
- Infants exposed to nicotine
- Infants with prenatal illicit drug exposure
- Infants of young mothers (under 20)

## Which Babies Are at Greatest Risk?

- Male infants
- Multiples
- African Americans and Native Americans
- Infants who sleep in the prone position
- Infants who sleep on soft bedding
- Overheated infants

**Notes:**
Infants of young mothers, under the age of 20
Male infants
Multiples
African Americans
Native Americans 
Infants who sleep in the prone position
Infants who sleep on soft bedding
AND
Overheated infants

While these risk factors don’t necessarily cause SIDS, they are frequently associated with babies that die of SIDS. Risk factors can play an important part in the chain of events culminating in a SIDS death. It is believed that in some cases the elimination of a risk factor can alter the outcome, influencing the baby’s ability to survive.

## Which Babies Are at Greatest Risk?

- Premature infants and/or low birth weight infants (under 1000 grams)
- A recent study showed that premature infants were 17 times more likely to die of SIDS than term infants.

**Notes:**
Premature infants and low birth weight infants are at the greatest risk for SIDS. The risk increases with decreasing gestational age or birth weight.
The other babies at high risk include:
Infants of mothers with late/no prenatal care
Infants exposed to nicotine prenatally
Infants with prenatal illicit drug exposure
CONTINUED ON NEXT SLIDE...

## Some Theories...

- Researchers have identified an area of the brain that is hypoplastic or absent in SIDS babies
- Medullary arcuate nucleus
- This abnormality may put an infant at risk for sudden death during sleep
- This area of the brain regulates autonomic and respiratory control during sleep

**Notes:**
There are many theories and risk factors for SIDS, and it may be that all babies who die of SIDS do not die for the same reasons.
Through examining the brainstems of infants who died with a diagnosis of SIDS, researchers have identified an area of the brain called the medullary arcuate nucleus that is frequently hypoplastic or absent in SIDS babies. The arcuate nucleus controls an infant’s protective responses to changes in oxygen and carbon dioxide levels. What this means is that babies who have this defect may be unresponsive to life threatening challenges during sleep. Babies with this defect may not respond the way a normal baby would to sleeping environment challenges such as a soft blanket or a warm room.

## Some Theories...

- The Atlas-VSC-SIDS Theory
- Suggests misalignment of the spine, caused by abnormal positioning in utero or by the birth process, can cause the cardiovascular and respiratory systems to malfunction, leading to sudden death during a vulnerable postnatal period.

**Notes:**
The Atlas-VSC-SIDS Theory suggests that misalignment of the spine, caused by abnormal positioning in utero or by the birth process, can cause the cardiovascular and respiratory systems to malfunction, leading to sudden death during a vulnerable postnatal period.

## Triple Risk Model

- 1. Critical Stage Of
-     Development

- 2. Vulnerable
-     Infant

**Highest risk for SIDS**

- Highest risk at 2-4 months

- External risk factors such as smoking, poor sleep position, etc.

- Arousal
- response deficit or subtle brainstem dysfunction

- SIDS

- 3. Exogenous
-     Stressors

**Notes:**
A triple-risk model is often used to describe the confluence of events that may lead to the sudden death of an infant:

The first element of the model is the critical development period. This element encompasses the period of rapid growth phases during the infant’s first six months of life which may periodically destabilize the infant’s system. During the developmental period, changes occur in homeostatic controls, such as sleeping and waking, breathing, heart rate, blood pressure and temperature. 

The second element of the model is the vulnerable infant. The vulnerable infant represents an infant with an underlying defect or abnormality. In this model, there are pathophysiological reasons behind these seemingly sudden deaths, such as defects in regions of the brain that control respiration, and heart rate during early life. 

The third element of the model involves exogenous stressors, outside or environmental challenges which a normal baby can overcome and survive, but that an already vulnerable baby night not. In this model, stressors such as exposure to tobacco smoke, prone sleep position or an upper respiratory infection alone do not always cause death for the infant, but they may further tip the balance against an infant’s chances of survival. 

According to this model, when all three elements come together, SIDS is the end result. 

Since many of our patients are vulnerable infants and all are under a year of age, according to this model, reducing the likelihood of exposure to exogenous stressors is crucial for our patients.

Scientists continue to search for the cause of SIDS. SIDS, like other medical disorders, may eventually have more than one explanation and more than one means of prevention. This may explain why the characteristics of SIDS babies seem so varied.

## The Importance of NICU Staff in Stopping SIDS

- A recent national study found that recommendations from the neonatal nursery staff increased the likelihood of parents following through with supine sleeping and other SIDS guidelines.

**Notes:**
Now let’s talk about what you can do! Although we don’t know what causes SIDS, we do know that there are risk factors associated with SIDS that can be eliminated. 
As nurses, It is extremely important that we are familiar with the National Guidelines for preventing SIDS, that we teach these guidelines to our patient’s parents, and that we model proper behaviors in the NICU. 
A recent national study found that recommendations from the neonatal nursery staff increased the likelihood of parents following through with supine sleeping and other SIDS guidelines.

## Behaviors That Should Be Taught To Parents To Reduce the Risk of SIDS

- Always place your baby on his or her back to sleep, even for naps.
- Place your baby on a firm mattress in a safety-approved crib or bassinet.
- Remove soft, fluffy bedding and stuffed toys from your baby’s sleep area.
- Make sure your baby’s head and face remain uncovered during sleep.

**Notes:**
The following recommendations are based on the latest medical evidence on reducing the risk of SIDS. As healthcare providers we should teach these behaviors to parents to reduce their baby’s risk of SIDS:
1. Parents should always place the baby on his or her back to sleep, even for naps.
2. They should place the baby on a firm mattress in a safety-approved crib or bassinet.
3. They should remove soft, fluffy bedding and stuffed toys from the baby’s sleep area.
4. They should make certain that their baby’s head and face remain uncovered during sleep.
CONTINUED ON NEXT SLIDE...

## Behaviors That Should Be Taught To Parents To Reduce the Risk of SIDS

- Do not allow smoking around your baby.
- Do not let your baby get too warm during sleep.
- Talk to childcare providers, grandparents, babysitters and all caregivers about SIDS risk.

**Notes:**
5. They should never allow smoking around the baby
6. They should not allow the baby to get too warm, or overheat, during sleep.
AND FINALLY,
7. They should talk to childcare providers, grandparents, babysitters and all caregivers about the risk factors associated with SIDS.

## Always place your baby on his or her back to sleep, even for naps.

- The American Academy of Pediatrics has recommended since 1992 that infants be placed to sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS).
- Infants who sleep on their backs are 3 times less likely to die from SIDS than those who sleep on their stomachs.

**Notes:**
 Let’s examine each of these recommendations a bit more closely...
The American Academy of Pediatrics has recommended since 1992 that infants be placed to sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS). 
Since that time, the frequency of prone sleeping in the US has decreased from 70% to 20%, and the SIDS rate has decreased by 50%.
Placing babies on their backs to sleep is the single most important step that parents and other caregivers can take to reduce the risk of SIDS. 
Infants who sleep on their backs are 3 times less likely to die from SIDS than those who sleep on their stomachs. 
Infants who fall asleep on their stomachs should be gently turned onto their backs. 

## Always place your baby on his or her back to sleep, even for naps.

- Side sleeping
- While better than prone sleeping, it still has twice the risk of SIDS as back sleeping.
- Stomach sleeping
- Babies sleeping on their stomachs have lower blood pressure, higher heart rate and higher body temperature.
- Arousal may be diminished in the prone position
- These babies are also more likely to overheat & to rebreathe CO2.

**Notes:**
While side sleeping is better than stomach sleeping, it still has twice the risk of SIDS as back sleeping. Also the side position is not very stable; many of these babies will roll into the stomach-down position.

Stomach sleeping has been shown to increase the risk of SIDS. Information from a recent study comparing babies sleeping on their backs and on their stomachs indicates that babies sleep better on their stomachs. They have lower blood pressure, higher heart rate, higher body temperature and less less periods of arousal. These factors may contribute to a SIDS terminal event if a child has a decreased ability to regulate his or her arousal response.
Babies on their stomachs are also more likely to overheat and to rebreathe carbon dioxide.

## The Back To Sleep Program

- Since 1994, when the Back To Sleep advisory was first announced, the rate of SIDS deaths in the U.S. has dropped by 50%.
- When babies all slept on their stomachs, there were approximately 5000-6000 deaths per year.
- There were just over 2,000 deaths due to SIDS in 2003.

**Notes:**
Since 1994, when the Back To Sleep advisory was first announced, the rate of SIDS deaths in the U.S. has dropped by 50%. 
When babies all slept on their stomachs, there were approximately 5000-6000 deaths per year.
There were 2,583 deaths due to SIDS in 2001.
CONTINUED ON NEXT SLIDE...

## What About Aspiration?

- According to the AAP “there is **NO **evidence of an increase in aspiration or increased complaints of vomiting since the incidence of supine sleeping has increased dramatically” (AAP, 2000).
- There is also some “direct and indirect evidence that infants who vomit are at **greater risk** of choking if they are sleeping face down” (AAP, 2000).

**Notes:**
Many parents are still concerned that their babies will choke or aspirate while sleeping in the supine position.
It is important to explain to these parents that their babies are not at a greater risk for aspiration on their backs. 
The SIDS Alliance reports that rate of aspiration has not increased since the BTS campaign was initiated and, according to the AAP, “there is NO evidence of an increase in aspiration or increased complaints of vomiting since the incidence of supine sleeping has increased dramatically” (AAP, 2000).
There is also some “direct and indirect evidence that infants who vomit are at greater risk of choking if they are sleeping face down” (AAP, 2000). 
Infants have what are called laryngeal chemoreflexes that control swallowing, laryngeal closure, cough, and arousal from sleep. They remove fluids and prevent aspiration. These reflexes are competent in the supine position, however airway protection may actually be compromised in the prone position. This makes sense if you think about our anatomy. In the prone position, the trachea sits on top of the esophagus, so anything regurgitated prone will pool in the larynx and drain into the trachea.  

## Place your baby on a firm mattress in a safety-approved crib or bassinet

- Never place babies to sleep on a waterbed, sofa, or cushions.
- A safe crib is in good repair with a firm mattress and the slats are 2 3/8” apart (close enough so that a soda pop can cannot fit between them).

**Notes:**
The second recommendation warns that
Infants should not be put to sleep on waterbeds, sofas, soft mattresses, or other soft surfaces.
Parents are advised to use a firm mattress in a safety-approved crib or bassinet for their baby's safest sleep
 A safe crib has:
no missing or broken hardware 
slats no more than 2 3/8" apart (close enough so that a soda pop can cannot fit between them)
no corner posts over 1/16" high
no cutout designs in the headboard or footboard
a firm, tight-fitting mattress (a mattress is too loose if you can fit more than two finger-widths between the edge of the mattress and the crib side).
a safety certification seal (on new cribs)
Parents should beware of second-hand, hand-me-down, or family heirloom cribs, cradles, mattresses or other bedding items that may not meet current safety standards.
They can check on the U.S. Consumer Product Safety Commission’s website to make certain that the crib has not been recalled. 

## What About Bed Sharing?

- NOT protective against SIDS
- The AAP discourages bed sharing
- Bed sharing does become unsafe and confers a higher risk of SIDS when...
- Parents smoke and bed share
- Parents are exhausted or under the influence of alcohol or drugs.
- Encourage rooming in rather than bed sharing.

**Notes:**
Bed sharing is popular practice and it has been publicly praised as a good way to boost breastfeeding and mother-child bonding. Some even claim that bed sharing reduces the risk of SIDS.
However bed sharing has drawn criticism from safety experts concerned about the potentially hazardous conditions presented by the family bed or sofa. 
Bed sharing is not recommended by the American Academy of Pediatrics or the National SIDS Alliance.
When parents bed share there is a great risk of rolling over on to the infant and of the infant becoming trapped in an adult bed if the mattress pulls away from the headboard. Pillows and comforters in the family bed are also dangers for a sleeping infant. 
When infants sleep in the same bed with parents whose instincts are impaired by exhaustion, drugs or alcohol, or with parents who are smokers, their risk for SIDS actually increases.  
Encourage parents to try rooming in with the baby, not sleeping in the same bed.  

## Remove soft, fluffy bedding and stuffed toys from your baby’s sleep area.

- Eliminate soft bedding such as quilts or pillows from cribs.
- If using a blanket, use a thin one and tuck it around the mattress so it reaches only as far as the baby’s chest.
- Remove bumper pads from cribs.
- Remove wedges from cribs.
- Do not place stuffed animals or toys inside the sleeping area.
- Make certain crib sheets fit well.

**Notes:**
The third recommendation warns that...
Parents should avoid using loose, fluffy blankets or coverings and should not use pillows, sheepskins or comforters under the baby.
Asphyxiation by carbon dioxide is associated with soft bedding because the infant can get the his/ her face against it and rebreathe carbon dioxide throughout the night. According to the Consumer Product Safety Commission, as many as 1/3 of the deaths attributed to Sudden Infant Death Syndrome may be caused by suffocation in soft bedding,. 
Parents should avoid the use of bumper pads and wedges. They are not recommended and can be hazardous to the baby. They should also remove all stuffed animals and toys from the baby’s sleeping area. If anything is not firm in the bed, the baby’s face can be trapped in a “pocket” of carbon dioxide, which is what many researchers say is the most common exogenous stressor related to SIDS.
If parents insist on using bumper pads, they should be thin, flat and fastened securely.
If parents use a blanket, it should be a thin one and it should be tucked around the mattress so it reaches only as far as the baby’s chest. You can also recommend a warm sleeper as an alternative to blankets.
Parents should never use a crib sheet unless it fits securely on the crib mattress.
Since 1984, The U.S. Consumer Product Safety Commission (CPSC) Has warned caregivers about the risk of asphyxiation from loose or oversized sheets in babies' cribs.

## Make sure your baby’s head and face remain uncovered during sleep.

- Avoid using a blanket or other coverings over your baby's face as a sun or weather screen.
- Do not swaddle the baby’s head.
- Consider using a sleep sack
- as an alternative to a blanket.

**Notes:**
The fourth recommendation is that...
Parents should make sure that their baby's head and face remain uncovered during sleep. Babies are at an increased risk for SIDS if their head becomes covered during sleep. 
Parents should avoid using a blanket or other covering over the baby's face as a sun or weather screen, or to block out distractions or sounds while the baby is sleeping. 
They should not swaddle the baby with the blanket covering the baby’s head. Some studies suggest that a babies thermal resistance increases by 300% if the head is fully covered, which can lead to a lethal rise in brain temperature.  Even thin blankets can pose a threat. 
Recommend that parents consider using a sleep sack as an alternative to a blanket. Bedding that bunches up or contours around a baby's face can obstruct the mouth and nose, causing potentially dangerous re-breathing of stale air. CONTINED ON NEXT SLIDE....

## Do not let your baby get too warm during sleep.

- Keep the temperature in the baby's room at a level that feels comfortable.
- Room temperature should be about 70 degrees.
- Dress a baby in as much or as little as an adult would wear.
- Remember to remove hats and heavy outerwear when indoors during the cold weather months.
- Limit layers of clothes and blankets in warmer weather.

**Notes:**
On to recommendation number five...
Caution parents to be careful not to overheat their baby. Babies should be kept warm, but they should not be allowed to get too warm. An overheated baby is more likely to go into a deep sleep from which it is difficult to wake up.
Research findings indicate that overheating a baby with too much clothing, too heavy bedding, and too warm a room increases the risk of SIDS, particularly if a baby already has a fever. 
Signs that a baby may be overheated include sweating, damp hair, heat rash, rapid breathing, and restlessness. 
Babies cannot regulate their own body temperature well. When challenged by thermal stress, an infant's heart, lung and sweat glands must work harder to cool down.  
Parents should set the thermometer to whatever temperature they find most comfortable and dress their baby in as much or as little as they would wear. For babies that are not yet 5 pounds parents should dress them accordingly and add one layer.
Remind parents to remove the baby's hat and heavy outerwear when indoors, in cars, or in stores to keep the baby from becoming overheated during the cold weather months, and limit layers of clothes and blankets in warmer weather.
Remind parents not to go to extremes. While overheating is as a risk factor for SIDS and we should encourage parents to avoid overdressing their babies for sleep, it is important to note that infants who were wearing too little clothing while sleeping in too cool an environment have also died of SIDS. 

## Do not allow smoking around your baby.

- Nicotine is a neuroteratogen
- Causes cell damage
- May shut off the fetal response to hypoxia
- May disrupt the rhythmic organization of autonomic function (Zeskind, 2000)
- Babies whose mothers smoke have 3X the risk of SIDS as babies born to non-smoking mothers.
- Exposure to other passive smokers increases the risk in a dose-dependent manner (Flemming, et. al, 2000).

**Notes:**
Next...
Advise parents not to smoke around their baby and to avoid second hand smoke exposure around their baby.
Smoking has CONSISTENTLY been identified as a risk factor for SIDS in almost EVERY epidemiologic study of SIDS.
Nicotine is a neuroteratogen. It causes cell damage that can interfere with an infant's developing lungs and nervous system.
 It has been proven to disrupt a baby's ability to wake from sleep and  to shut off the fetal response to hypoxia.
A mother’s smoking during pregnancy increases an infants chance 3 times for having SIDS.
A mother’s smoking post-pregnancy doubles the infant's risk.
Increased risk due to exposure to second hand smoke from a father or other family member is dose related.  The more the baby is exposed to smoke, the greater the risk. The risk of SIDS also rises with each additional smoker in the household
If you know that a family member smokes, explain the risks and offer to refer them to the Healthsource smoking cessation program.

## Talk to childcare providers, grandparents, babysitters and all caregivers about SIDS risk.

- About 20% of the babies that die of SIDS each year die while being cared for by someone other than their parents.
- Half of these children die in their first week of day care.
- Babies unaccustomed to sleeping on their stomachs are at significantly increased risk.
- Parents should tell caretakers that they want the baby to sleep on his/ her back, even at nap time.

**Notes:**
The final recommendation is to talk to childcare providers, grandparents, babysitters and all caregivers about SIDS risk.
20% of babies who die of SIDS do so while in the care of a child care provider.
Half of these children die in their first week of day care.
Why does this happen?
Often because the babysitter doesn’t know about the importance of putting babies on their backs.
Only 1/4 of licensed daycare centers are aware and actively adhering to the back to sleep guidelines.
Grandparents and other senior caregivers are still resistant to the recommended change in infant sleep position.

Babies who routinely sleep on their backs and are unaccustomed to sleeping on their stomachs are at significantly increased risk of SIDS when placed prone by a well-intentioned but ill-informed relative or care giver. 
In November 1999, the Archives of Pediatric and Adolescent Medicine published a study that found the risk of SIDS to be 18 times higher among infants unaccustomed to being positioned prone who are then placed prone for sleep. 
Continuity of care is an essential component of SIDS risk reduction Remind parents to tell all caretakers that they want the baby to sleep on his/ her back, even at nap time.

## Safe Sleeping

- Ideally this is how an infant under 1 year of age should sleep
- He is on a firm, flat mattress in a crib that meets safety standards.
- There are no quilts, pillows or toys in the crib.
- The baby is placed with his feet at the foot of the crib.
- The blanket being used is thin and it is tucked around the crib mattress, reaching only as far as the baby's chest.

**Notes:**
Ideally this is how an infant under 1 year of age should sleep
He is on a firm, flat mattress in a crib that meets safety standards.
There are no quilts, pillows or toys in the crib. 
The baby is placed with his feet at the foot of the crib.
The blanket being used is thin and it is tucked around the crib mattress, reaching only as far as the baby's chest to lessen the likelihood of the infant crawling under it or pulling it over his face. 

## Modeling Proper Behaviors In The NICU

- Research shows that parents model behaviors seen in the hospital.
- Stomach sleeping in the hospital = stomach sleeping at home
- Same is true for nesting, bundling with multiple blankets, stuffed animals in the bed and placing the head of the bed up

**Notes:**

“Research has proven that parents tend to observe the manner in which their child is cared for in the NICU and are likely to mimic baby care practices witnessed during the hospital stay”.
Basically,
Stomach sleeping in the hospital = stomach sleeping at home.  
The same is true for nesting, bundling the baby with multiple blankets, placing stuffed animals in crib, and placing the head of the bed up.

Let’s take at look at what parents see in the NICU. All of these photos were taken on one day in our NICU and are of babies going home within six days.

## Modeling Proper Behaviors In The NICU

- In the study that showed premature infants were 17 times more likely to die of SIDS than term infants, much of the risk was attributed to poor behaviors learned in the nursery.

## 

	What do parents see in the NICU?

- 	What do parents see in the NICU?

## The head of the bed is up. The baby is nested with a stuffed animal and quilt in the bed.  She is in the side sleeping position.

## The baby is sleeping prone with multiple layers of soft bedding.

## There is a covering over the baby’s face and there are multiple objects in the sleeping area.

## The baby is nested and is in the side sleeping position with his face against the soft bedding. 

## There is a heavy, non-secured covering over the baby’s face and the head of the bed is elevated. This is a baby who never had issues with emesis or reflux.

## This baby’s bedding is covering her mouth and nares. She had 6 blankets in the crib.

- 	      Learning from Our Mistakes
- 			  And Taking Action

## What We Learned

- Neonatal hospital staff can unwittingly be poor role models.
- Prone positioning, elaborate nesting and the use of soft bedding or gel pillows may be quite safe within the confines of the critical care setting but are potentially lethal at home.

**Notes:**
As you can see, Neonatal nurses can unwittingly be role models for practices that conflict with the AAP SIDS prevention guidelines and are unsafe upon discharge from the NICU.
Prone positioning, elaborate nesting and the use of soft bedding or gel pillows may be quite safe within the confines of the critical care setting but are potentially lethal at home.

## Taking Action...

- Staff members were asked to volunteer for a SIDS Prevention Task Force.
- The multidisciplinary task force met weekly to discuss the current recommendations for preventing SIDS and how we could better incorporate them in to our NICU.
- The goal of the task force was that all infants would be following the AAP’s recommendations for sleep before their date of discharge.

## The Guidelines...

**Notes:**
Apparently contradicting all of these SIDS reduction recommendations is the concept of developmentally supportive care for our high-risk infants.  Many premature infants or physiologically compromised full-term infants benefit greatly from interventions such as prone positioning and “nesting” with soft bedding.
The article you have in your packets examines the question “Is there room in the crib for both the AAP SIDS reduction recommendations and developmentally supportive care?”
The answer the authors come up with is that we will probably find plenty of space for both if we re-examine our own nursing practice and carefully consider each child’s  changing clinical status, gestational maturity and individual readiness for supine sleeping with minimal bedding. 
As NICU nurses, we need to consider the ultimate goal of helping high-risk babies become healthy babies. We need to ask ourselves “How can I best apply the principles of developmentally supportive care yet prepare families to follow AAP recommendations for infant sleep after discharge?”
While the education of the parents that we have discussed is critical, so is modeling...

## Slide 46

## Slide 47

## The Task Force

- The task force developed these guidelines based on the current recommendations, personal experience, standards for supporting developmentally appropriate care, and the opinions of experts in the field.
- The task force agreed that guidelines would be more effective than a policy, recognizing that there will always be variations from the norm in our patient population.
- The guidelines are divided into 3 categories: babies less than 32 weeks CGA and/or <1500 grams, babies between 32 and 35 weeks CGA and/or >1500 grams, and babies over 35 weeks CGA.

## Changing Our Practice

- Sleep position and conditions should be adjusted to follow the AAP guidelines as soon as the baby is physiologically and developmentally ready.
- If a baby is expected to follow any guidelines for sleeping other than the AAP SIDS Prevention Recommendations, they should have specific written instructions and the physician should discuss the alternate interventions with the family.

**Notes:**
At home, after discharge, our former NICU patients should be placed flat on their backs to sleep with minimal bedding in the crib.  An infant’s sleep position and conditions should be adjusted to follow these AAP guidelines as soon as the baby is physiologically and developmentally ready.
Following this rule not only promotes safety, but sanity . Research has shown that infants who have been nested for containment and have consistently slept in the prone position or with the head of the bed elevated, are going to find it difficult to sleep unless those conditions are duplicated. The baby’s first weeks at home are stressful enough for new families without a new sleep position being introduced to a less-than-cooperative infant.  
The only exceptions to this rule would be babies with extremely severe reflux or airway anomalies. In our NICU, if a baby is expected to follow any guidelines for sleeping other that the AAP SIDS prevention guidelines, they will have specific written instructions, and the physician will sit down with the family and discuss the alternate interventions.

## Sharing Our Wisdom

- The task force also developed a parent handout to explain the transition process for preterm infants as they grow closer and closer to term CGA
- If a patient is getting ready to go home and staff is unable to follow the SIDS prevention guidelines, an explain of why alternate practices may be acceptable in the hospital setting but not at home is given.
- No more waiting until the day of discharge to review the SIDS Prevention Recommendations!

## What We Learned

- There is room for both Developmentally Supportive Care and SIDS Prevention Recommendations in the NICU.
-  We need to carefully consider each child’s changing clinical status, gestational maturity and individual readiness for supine sleeping with minimal bedding.
- The ultimate goal is to help high-risk babies become healthy babies

## Remember, You Can Make A Difference!

- Be aware of the risk of SIDS for our vulnerable patients as they transition to home.
- Use your influence as healthcare professionals, through education and modeling, to minimize the risk!

**Notes:**
At the end of the article there is a policy with recommendations for transitioning sleep position and the use of bedding materials, and recommendation regarding parent education strategies. You may wish to look this over and incorporate these suggestions into your nursing practice.
You will be seeing more information on this topic as it relates to our NICU in the future. In the meantime, please be aware of the Risk of SIDS for our vulnerable patients as they transition to home, and use your influence as nurses, through education and modeling, to minimize the risk. 
Thank you.

## For More Information

- The National Institute of Child Health and Human Development
-    _www.nichd.nih.gov_, Back to Sleep
- SIDS Mid-Atlantic
-    703-933-9100
-    _www.sidsma.org_

**Notes:**
If you want more information on strategies to prevent SIDS here are the contacts.

## For More Information

- American Academy of Pediatrics
-    _www.aap.org_
- Association of SIDS and Infant Mortality Programs
-    _www.asip1.org_

## For More Information

- National SIDS Resource Center
-    _www.sidscenter.org_
- SIDS Alliance
-    _www.sidsalliance.org_

## References

- 		American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. (2000).  Changing concepts of sudden infant death syndrome:  implications for infant sleeping environment and sleep position.  [on-line].  _Pediatrics, 105,_ (3), 650-656.
- 		Hudson Mohawk SIDS Affiliate. (1998).  Reducing the risk of SIDS: what public health nurses need to know.
- 	Kemp, J. S. & Thach, B. T. (1995).  Quantifying the potential of infant bedding to limit CO2 dispersal and factors affecting rebreathing in bedding.  _American Physiological Society,_  740-745.
- 		Lockridge, T., Taqino, L. T., Knight, A., (1999).  Back to Sleep:Is there room in that crib for both AAP recommendations and developmentally supportive care?  _Neonatal Network, 18_ (5), 29-31.

## References

- 		Moon, R., (2000). _Answering medical questions about SIDS_.  Presented at the National SIDS Alliance Conference, Salt Lake City, Utah.	Willinger, M., Ko, C. W., Hoffman, H. J., Kessler, R. C., Corwin, M. J. (2000)  Factors Associated with caregivers’ choice of infant sleep position, 1994-1998.  _JAMA, 283 _(16), 2135-2142.	Zeskind, P. S., (2000). _Maternal cigarette-use during pregnancy disrupts rhythmic activity in fetal autonomic regulation._  Presented at the National SIDS Alliance Conference, Salt Lake City, Utah