Safe Sleep Practices and Reducing the Risk of SIDS
Welcome to Safe Sleep Practices and Reducing the Risk of SIDS, developed and presented by the Indiana Child Welfare Education and Training Partnership. This training is available in different formats for State of Indiana employees and School of Social Work students. Scroll down the page for instructions on how to take this training.
State Employee Training #
State employees can take Safe Sleep Practices and Reducing the Risk of SIDS training through the State of Indiana’s Learning Portal (also known as SuccessFactors). If you’re already logged into My Learning in SuccessFactors, you can select the Safe Sleep Practices button to go directly to the training.
If you haven’t logged in, the Safe Sleep Practices button will take you to a log-in screen. After you’ve logged in, select the My Learning button. From there, you can search for this training by name (using the Find Learning search box) or come back here and use the direct training link.
For a video walkthrough of how to access this training, select the help button.
School of Social Work: Student Training #
Welcome
Welcome to the Indiana Department of Child Services Computer Assisted Training on Safe Sleep Practices and Reducing the Risk of Sudden Infant Death Syndrome, or SIDS. The information discussed in this training was adopted with permission from First Candle, National SIDS Alliance, part of the Indiana University School of Medicine.
Objectives
By the end of this training, participants will be able to:
- Define Sudden Infant Death Syndrome
- Understand risk factors associated with SIDS
- Describe the etiology of SIDS using the Triple‐Risk Theory
- Understand how unsafe sleeping practices increase the risk of infant deaths
- Share national safe sleep standards for reducing the risk of SIDS, and
- Provide educational materials and resources about safe sleep practices.
What is Sudden Infant Death Syndrome?
SIDS definition – The sudden and unexpected death of an infant younger than 1 year that remains unexplained after a complete postmortem examination including an autopsy, a review of the child’s case history, and a thorough death scene investigation.
A syndrome is a number of symptoms occurring at the same time that characterize a disease or condition. The use of the word syndrome when defining SIDS reminds us there may be multiple reasons why babies die suddenly. In addition, SIDS is puzzling because seemingly healthy babies can die from SIDS without warning.
- Experts cannot predict SIDS.
- SIDS cannot be prevented.
- Simply by following current national guidelines, we can reduce the risk of babies dying as a result of SIDS and suffocation.
National Statistics
According to the Centers for Disease Control and Prevention.
More than 4,500 infants born in the United States die unexpectedly each year, and approximately 50 percent of those deaths are due to SIDS, according to the Centers for Disease Control and Prevention. The Minnesota Sudden Infant Death Center estimates that nearly 1 in every 1,000 live births will result in a SIDS death. Sudden Infant Death Syndrome rates have declined, from 4,500 to 6,000 per year, to less than 2,500 per year, according to the American Academy of Pediatrics. As SIDS rates have declined, rates on other ways infants die have increased, largely due to more accuracy in diagnosing.
SIDS Facts
SIDS is the cause of death for approximately 2,500 babies per year. Nationally, SIDS is the leading cause of death for babies between 1 month and 12 months of age. The highest numbers of deaths occur between 2 and 4 months of age, and 91% of SIDS deaths occur between 1 and 6 months of age. Research suggests children are more likely to die of SIDS between November and March, when they are males, and when an infant is accustomed to sleeping on his or her back, and is then placed on their tummy to sleep while in the care of a person other than the primary caregiver. It is vital parents discuss their child’s sleeping practices with all possible caregivers. These facts are based on years of national data that show who, when, where, at what age, and under what circumstances babies die suddenly and unexpectedly. Data are derived from the National Institute of Child Health and Human Development and SIDS researchers.
- While the exact causes of SIDS deaths are unknown, research has shown that immunizations, vomiting, and/or choking, are not associated risk factors.
- It is important to remember SIDS is not the same as suffocation or asphyxia.
SIDS Risk Factors -Pregnancy
- Research indicates some infants are at a higher risk of SIDS because of certain risk factors such as low birth weight, prematurity, maternal smoking during pregnancy, multiple births, maternal age younger than 18 years and having less than 18 months between births.
- Remember, risk factors are not exact causes. Rather, there is an association between these dynamics and the risk of a SIDS‐related death.
Understanding SIDS Risk Factors
A greater understanding of the populations and behaviors associated with an increased risk of SIDS come from medical and behavioral research, death scene investigations, infant fatality reports, death certificate data, and epidemiology. Understanding who is at greatest risk for SIDS, and what behaviors increase the possibility of SIDS, helps guide awareness, education, and training efforts, to reduce potential risks. With this knowledge, precautions can be taken to minimize SIDS risks for babies.
Babies at Risk for SIDS
- Populations that have a higher risk of SIDS include African American babies, American Indian babies, babies whose mothers smoke during pregnancy, and babies who breathe secondhand smoke.
- In addition to increasing the risk for SIDS, maternal smoking also increases the chances of a baby being born prematurely, and with a low birth weight, both of which are additional risk factors for SIDS. Smoking cigarettes during pregnancy negatively affects the nerves and the brain of the developing fetus.
- Creating a smoke free environment is a critical step to nurturing the health and well‐being of infants and toddlers, and reducing the risk of SIDS.
- Other at risk populations include babies who sleep on their tummies and babies put on their tummies to sleep who usually sleep on their backs.
- While SIDS cannot be prevented, individuals should do all they can to reduce the risk of an unnecessary death. Paying attention to these risk factors could be the key to prevention.
African American babies have a greater risk for SIDS. The main factors associated with this higher prevalence rate are a higher rate of bed sharing, higher smoking rate among pregnant african american women, a higher percentage of parents with lower income, that results in less prenatal care, less available medical insurance, and in addition to these factors, research has linked higher rates of anemia, lower brain serotonin levels, and genetic heart tissue defects in African American infants who die of SIDS.
- SIDS rates tend to vary within Hispanic subgroups, though overall, Hispanics have a lower SIDS rate than other ethnicities.
- Central Americans, South Americans, and Mexican Americans have a lower rate of SIDS than Caucasians, and other Hispanic subgroups.
- Puerto Ricans have significantly higher rates than any other Hispanic group.
Triple Risk Theory to Explain SIDS
Researchers believe no single risk factor is likely to cause a SIDS related death. Rather, the combination of several risk factors may contribute to what causes an infant to die from SIDS. The Triple Risk Theory indicates that:
- First: The vulnerable infant is one with an intrinsic developmental defect that is undetectable.
- Second: The critical development period coincides with a period of rapid growth and development of the brain, during the first six months of life. Remember, 90% of all SIDS‐related deaths occur before six months of age.
- And the third, and only area where practice of child care providers and parents can make the greatest difference, is the external stressors, or environmental factors, such as smoking, sleeping on the stomach, loose bedding, and other risk factors previously discussed. Overheating is another modifiable stressor. Parents and caretakers should be cautious not to overdress a baby. Generally, if it is warm enough for you, it is warm enough for an infant.
Unaccustomed Tummy Sleeping
- A baby is at the least amount of risk when placed on their back to sleep.
- Increased risk of death (as much as 18-fold) Mitchell et al, 1999.
- Placing an infant on their tummy to sleep can increase the risk of death up to 18‐fold.
- Non‐parental caregivers unaware of American Academy of Pediatrics guidelines often use tummy sleeping which as discussed earlier, places children at a higher risk of SIDS.
- It is recommended that infants under one year of age be placed on their back to sleep, especially for those not accustomed to sleeping on their tummy, as these infants often have more trouble lifting their head to breathe fresh air.
Common Beliefs
- The most common fear associated with allowing a baby to sleep on his or her back is that the baby will choke if it spits up while sleeping.
- Some other reasons include comfort of the baby, fear of developing a flat head or a bald spot, startle response, and parent or child care provider preference. It is important to note that healthy babies will not choke if they spit up.
- Humans have evolved mechanisms that keep them from choking if they are lying on their backs. Usually, the spit‐up rolls down the side of the face, or is re‐swallowed.
- If a baby has a specific medical condition related to reflux or projectile vomiting, the baby’s pediatrician should be consulted about sleep position, and the information should be shared with all caregivers.
The Aspiration Myth
Vomit comes up from the stomach through the esophagus, or food pipe. If a baby is on their back, vomit has to go against gravity to enter the trachea, or wind pipe. If a baby lies on their tummy, the esophagus is on top, thus working with gravity, and making it easier for a baby to aspirate. The image displayed on your screen illustrates this concept in detail.
- The upper-respiratory anatomy with the baby in the back sleeping position the trachea (wind pipe) is above the esophagus (food pipe).
- The upper-respiratory anatomy with the baby in the stomach sleeping position the esophagus (food pipe) is above the trachea (wind pipe).
Tummy Time
While babies should sleep on their backs, it is important for them to receive proper tummy time during waking hours. Babies who are accustomed to sleeping on their backs typically cry when they are first placed on their tummy to play, so tummy time tends to work best when the baby is most energetic, content, and tolerant. Healthy babies need tummy time during waking hours to help them develop strong muscles, and avoid flat spots on their head. Parents are encouraged to place a baby on his or her tummy on a firm, safe surface, and play together or stay nearby to keep the baby safe. Additionally, parents and caregivers should avoid placing children in car seats, carriers, and bouncers for extended amounts of time.
What About Fussy Babies?
How can we support parents and caregivers who have a baby who has difficulty sleeping on its back?
Parents and caregivers should discuss the bedtime routines of infants.
Generally, back sleeping is a learned behavior. Many infants will learn to sleep comfortably on their back after a period of adjustment, even if they previously preferred an alternate position.
Bed Sharing
Bed sharing is defined as sleeping in the same bed or sleep area, and may be dangerous under certain conditions. Adults, other children, or siblings should avoid bed sharing with an infant. Research shows adults who choose to bed share with their infants increase the risk of accidental death, especially those who smoke or use substances such as alcohol and or drugs that may impair arousal. Also, adult beds are not designed with infant safety in mind. The safest place for a baby to sleep is in on a separate sleep surface, such as a crib playyard, portable crib and/or bassinett, which are designed with infant safety in mind. Remember, room sharing is safer than bed sharing. The safest place for a baby to sleep, for at least the first six months, is in a crib placed near your bed.
Infant Positional Asphyxia
Infant positional asphyxia usually occurs in a sleep setting when an infant’s body position, or an obstructive object, prevents the child from breathing properly. It is important to note that the infant’s mouth and nose do not need to be completely covered in order for suffocation to occur. Some common causes include inappropriate sleep surfaces, the entrapment of the infant’s head between slats on a crib or bed, or the obstruction of the infants nose and mouth by items such as blankets, bumper pads, pillows, and toys. These obstructions of breathing can lead to low oxygen levels, and when oxygen levels decrease, carbon dioxide levels increase, causing them to rise to a potentially dangerous level.
Unsafe Sleep Environment
It is imperative for parents and caregivers to properly supervise infants and toddlers to ensure the types of situations depicted in these images do not occur. Between January 1999 and December of 2001, the Consumer Product Safety Commission, or CPSC, reported more than 98 children under the age of 1 died after being placed to sleep in an adult bed. Many mattresses these days are made of memory foam, or have pillow tops. The CPSC identified four primary hazards of infants sleeping in an adult bed.
- Suffocation caused by an adult rolling on top of, or next to an infant.
- Suffocation when an infant gets trapped or caught between a mattress and headboard, nightstand, wall,or other rigid object.
- Suffocation resulting from a baby being face down on a waterbed, a regular mattress, or on soft bedding
such as pillows, blankets, or quilts, and - Strangulation in a headboard or footboard that allows part of an infant’s body to pass through an area
while trapping the baby’s head.
Take a moment and identify what makes the image on your screen an unsafe sleep environment.
If you noticed that the image on the left has a missing slat, which places a child at risk of strangulation, you are correct. Please also note that changing tables should not be used as a safe sleep surface.
It is best practice to put babies to sleep only in a safety‐approved crib. Chairs, sofas, water beds, or adult beds are not safe sleep surfaces, as babies can fall or become entrapped in crevices in the furniture, or between cushions.
Parents and caregivers may check current safety standards for cribs, by visiting or clicking on following the web addresses :
For the following picture, take a moment and identify what makes the image depicted on your screen an unsafe sleep environment.
If you said that the image shows a child sleeping with soft bedding and pillows, which increase the likelihood of suffocation, you are correct.
There is no evidence to support the usage of commercially available products that help maintain a baby’s back sleep position. Package labeling talks about endorsement by the AAP, but the endorsement is for the importance of a child to sleep on his or her back, not the actual wedge or positioning device. A baby monitor is another commercial device that misses the mark when relied upon for a baby’s safety. Babies cannot always make noise when they are in an unsafe situation, as is the case with positional asphyxia.
Toys, stuffed animals, bumper pads, and pillows, all increase the likelihood of an infant suffocating. Infants may move up agenst these items, continue to breathe the same air, and suffocate due to a lack of oxygen. Bumper pads were originally intended to prevent a child from strangulating him or herself because of the distance between slats on a crib. However, slats are now closer together, and there is no need for bumper padding. Remember, if you want to ensure child safety, decorate the child’s room, not their crib.
Safe Sleep Environment
A safe sleep environment meets the following criteria:
- There should be no tears in the mesh or fabric.
- All cribs should be safety‐approved with slats spaced not more than 2 and 3/8 inches apart. A soda can should not be able to fit between the slats. All slats should be firmly attached, with no gaps from missing slats.
- There should not be any missing, protruding, or loose screws, bolts, or hardware, and there should be no sharp edges, points, or rough wood surfaces.
- Corner posts or decorative knobs should be 1/16 of an inch or less, and there should not be any splits or cracks in the wood or plastic.
- There should be a firm, snug fitting mattress in the crib, portable crib, or playpen frame.
- The space between the mattress edge and crib frame should not be more than the width of two adult sized fingers, and the mattress should have a tight‐fitting sheet.
- Parents and caregivers should use a wearable blanket, or other type of sleeper, instead of blankets, to keep a baby warm and safe.
- The sleep sack, or wearable blanket, allows diaper changes without having to remove it, can be made of light or heavy fabric depending on the season, or temperature of the indoor environment, and allows the infant to move without the risk of becoming entangled.
- An alternative to sleep sacks is to layer the babies clothing, not their bedding.
- Put an undershirt and socks on the infant under their pajamas or sleeper.
Baby in a Safe Crib
The image displayed on your screen is from the Indiana Safe Sleep Network, and shows where, and how a baby should be placed for sleep. Note that the crib slats are all present, there is no bumper pad, the mattress fits snug inside the crib, and there is a tight‐fitting sheet covering it. The infant is dressed in a sleep sack, and is being placed on its back, in the center of the mattress.
Rolling Over
Babies develop a preferred sleeping position. Many babies will stay on their back, but others will roll over. It is important for parents and caregivers to lay a child down on his or her back, and let the child adopt their position. By the time the child easily rolls over, they are usually past the age of greatest risk for SIDS.
It is important to remember that once a baby starts rolling, nothing else should be in the crib with them, so that they do not accidentally roll into an item that could suffocate them.
Using a Pacifier
- Pacifiers may be used at nap time or bed time during the first year.
- There is some preliminary research indicating that pacifier use reduces the incidence of SIDS, however a pacifier should never be forced on a baby that does not want it.
- For nursing babies, pacifiers should be introduced after breastfeeding has been established.
- Pacifiers should not be used in place of feeding.
- Parents and caregivers should consider using a clean, dry pacifier when placing an infant down to sleep.
Bedtime Basics for Babies Campaign
The Bedtime Basics for Babies Campaign provides eligible families across Indiana with a safe sleep environment. The Bedtime Basics for Babies kit has everything you need to keep your baby safe while sleeping. Families also receive educational resources.
Families eligible for this program must meet the following criteria:
- Currently no crib is available for an infant.
- Low-income status (Medicaid, CHIP, and WIC program eligibility or living at or below the poverty level).
- At least one risk factor for SIDS and sleep-related death (African American, American Indian/Alaska Native, tobacco exposure, pre-term, low birth weight, or SIDS sibling).
- FCMs refer families to First Candle/National SIDS Alliance through:
- Indiana University Department of Pediatrics Phone: 1 (866) 599-6419
Please note that all forms and educational resources available through First Candle, are available in both English and Spanish. Educational resources may be ordered free of charge.
Additional Resources
Listed on this slide are some additional resources to utilize when discussing, and educating others on safe sleep practices and SIDS.
Department of Child Services Policy
It is important for Family Case Managers to know that unsafe sleeping practices are not recognized as a form of neglect in Indiana, unless some form of parental impairment is suspected. Still, unsafe sleep practices do result in numerous infant deaths each year.
If impairment is suspected, Law Enforcement, and the Department of Child Services, may request that the parent submit to a drug screen within 3 hours of the child’s death, and based on the findings of the drug screen, and the parents behaviors on scene, substantiate a neglect finding.
Please refer to DCS Policy 4.31 for more information
Summary
In this training module, you have learned what SIDS is, and what SIDS is not, some of the risk factors for SIDS, how to reduce the risk of potential asphyxia, and you have been provided with resources for additional information on SIDS. Remember, the national standard on sleep positioning is consistent with, and incorporates the standards recommended by the AAP, SIDS Resource Center, and National Resource Center for Health and Safety in Child Care.
