Safe Infant Sleep in NICU


Approved by Clinical Guidelines Committee
March 2013
clinical guidelines back newborn home


New Zealand has high rates of sudden infant death compared to other developed countries. At rates of 1.1 deaths per 1000 live births, and more than twice these rates for Maori, about sixty babies die each year in this way1. Currently, most sudden infant deaths are considered preventable, whatever term is used (cot death, SIDS, SUDI, SUID, unascertained, sleep accidents). Importantly, most are associated with known risk factors and accidental suffocation is on the rise as a clear cause of death.

ADHB has a written policy on safe infant sleep. However, preterm, small and sick term infants are particularly vulnerable so this separate policy has been written for use in NICU.


Success with the adoption of safety advice over 25 years has led to dramatic falls in preventable infant mortality. Residual deaths are clustered in babies living in deprived circumstances, in Maori and, to a lesser extent, Pacific babies, and in babies exposed to smoking, especially in pregnancy. The peak age of death is 2 months, and 20% of deaths are babies older than 5 months.

Sudden infant death is understood within the ‘triple risk’ model 2 where three conditions combine to increase risk for babies. These are the critical stage (risks related to development), vulnerability (risks intrinsic to a particular baby) and sleep environment (extrinsic risks factors that can be modified).

Authors of the ‘triple risk’ model conclude that:
“Current evidence suggests that SIDS involves a convergence of stressors that probably results in the asphyxia of a vulnerable infant who has defective cardiorespiratory or arousal defence systems during a critical developmental period when immature defence mechanisms are not fully integrated.”

The NICU population, particularly those born prematurely, should be considered the most vulnerable of babies. Prevention, therefore, requires attention to all three spheres of risk as this is much higher in combination compared with an individual risk factor.

Selected definitions

Sudden infant death: Sudden death of an infant under one year of age which is unexpected by caregivers and may be unexplained.

Co-sleeping: When a baby and other(s) fall asleep together on the same surface (e.g. bed, couch, chair, floor, mat ) and the baby is not also in a baby bed (e.g. pepipod or wahakura).

Safe infant sleep: Conditions that promote breathing throughout the sleep episode. Specifically: a baby lying flat and on the back in a baby bed, on a firm and fitting mattress, with bedding tucked securely so as not to come loose (or no bedding and baby in a sleep sac), the space bare and face clear, baby breathing smoke free air, and in the same room as a sober carer when that carer is asleep.


The purpose of this policy is to provide clear direction for coordinated action on safe infant sleep in the NICU at ADHB.

Policy statement

Sharing of beds within NICU or the parent room for settling, night-time feeding, is unsafe and parents must be informed of this fact.

ADHB is committed to all babies having a safe sleep, in every place and at every sleep, in all locations within NICU, including when rooming in the parents room.

ADHB will support its staff with safe infant sleep education, intervention expectations, documentation systems, resources to use with families and feedback on key performance targets.

ADHB will support families with easy access to smoking cessation services, education on safe sleep and breastfeeding.

ADHB will measure impact of this policy against promoted targets for safe sleeping in SCBU/NICU environments and documentation of safe sleep discussions and uptake of smoking cessation support.


This policy applies to NICU in ADHB and separate policy exists for other settings where babies under one year may sleep.


This policy is underpinned by the following principles: a child’s right to protection, a parent’s right to know about sleep related risks for babies and how to avoid them, consistency in advice given, accountability of staff to DHB practice guidelines. Parents should have access to enabling strategies as needed such as smoking cessation support and the ‘triple risk’ evidence for a package of care, equity and fairness to redress mortality variations.


The majority of NICU babies are going to be on cardio - respiratory monitoring until approaching discharge. Whilst on this monitoring it may be safe for them to sleep in positions other than on their back. However, it should be explained clearly to parents that this should not be the case once they are no longer receiving such monitoring. Once the babies have graduated to an apnoea monitor or no monitoring they should be placed on their backs for all sleep periods.

All staff to promote; lying flat (level surface) and on the back, cot bare and face clear, close by yet in own bed/space. Staff also to promote breastfeeding and smokefree, with any and all exceptions documented. Staff should not shy away from informing parents that the dangers of not ensuring safe sleep could include infant death.

Standard care defined as e.g. ask about sleeping arrangements, be clear about conditions essential for babies and why, and check support for enabling safe action by parents at home (A=ask, B=be clear, C=check).

Role expectations of staff made clear in employment agreements and new staff orientation, and addressed in performance reviews and previews.

Staff education to include safe sleep evidence, practice guidelines, documentation systems and performance targets.

Practice Guidelines

ADHB NICU supports:

Modelling safe infant sleep where babies are placed flat (on a firm and level surface) and on their backs, with cot bare and face clear, and bedding firmly tucked in.

Sleeping on the back where babies are placed for sleep on their backs.

Sleeping flat where beds are made level when babies sleep

Being smoke free where brief smoke free interventions and intensive cessation support are provided to all parents who smoke as per the DHB smoke free policy

Breastfeeding where mothers of new-borns are supported to breastfeed exclusively as per the DHB breastfeeding policy,

Night time feeding where consideration is made for safety – in NICU this should be done in a chair to avoid the mother unintentionally fall asleep while feeding her baby

Rooming in where babies are sleeping in baby beds in the same room as their mothers (in hospitals) or fathers/carers.

Skin to skin contact between parents and babies when the parent is alert, awake and responsive to their babies, returning them to baby beds before parents fall asleep.

Swaddling where the material is light weight and always firm around the shoulders, loose around the hips and clear of baby’s face (used only for babies unable to roll and lying on their backs)

Clothing that is light weight and 1-3 layers

Bedding that is light weight such that it drapes a baby’s body, is firmly tucked and 1-3 layers.

Settling where parents are supported to apply conditions to help settle babies for sleep that include: firm wrapping/tucking across the shoulders (feeling held), proximity to carer (feeling close) and repetitive soothing actions (feeling rhythm).

Head shape where a baby’s head is gently turned from side to side each sleep to vary where it rests with periods of tummy time and upright time when baby is awake (30 minutes / day).

Supervision where situations requiring a mother to be supervised when with her baby are specified along with the degree/frequency of supervision required (e.g. C-section, medicated, obesity, extreme tiredness)

Documentation of all and any exceptions in clinical records for why e.g. a baby bed is not flat, a baby is not on the back, a smoking parent does not receive smokefree support.

ADHB NICU does not support:

• Babies sharing their parents’ bed even when the parents are alert because there is a real risk of falling asleep. For this reason parents should be told that the situation is dangerous and the baby would be at risk of suffocation and death.

• Side lying position for breast feeding in the parent room

• Sleeping of twins in the same bed within the parent room
• Note - If a parent is struggling to settle a baby it is appropriate to seek help from NICU staff and parents should be informed of this before entering the parent room.

Associated/supporting documents and sites

1 Child and Youth Mortality Review Committee, Te Ropu Arotake Auau Mate o te Hunga Tamariki, Taiohi, 2009. Fifth Report to the Minister of Health. Reporting mortality 2002-2008. Wellington:CYMRC
2 Kinney HC and THach BT. The Sudden Infant Death Syndrome. N Engl J Med. 2009 August 20; 361(8): 795–805. Letter from the Health Quality & Safety Commission New Zealand regarding safe sleep policies and SUDI Prevention. June 2012
3 Perinatal and Maternal Mortality Review Committee: Third Report to the Minister of Health: July 2008 to June 2009. Available at:
4 Trachtenberg F L , Haas, E A, Kinney, H C, Stanley C, Krous, H. Risk Factor Changes for Sudden infant Death Syndrome after initiation of back to sleep campaign. Pediatrics, 2012, March; DOI: 101542/peds.2011-1419
5 Ball H L, Volpe L E. Sudden Infant Death Syndrome (SIDS) risk reduction and infant sleep location – Moving the discussion forward Social Science & Medicine Available online 21 April 2012.
6 Tipene-Leach, D, Abel S. The wahakura and the safe sleeping environment. Pounamu J of Primary Health Care. 2010. 2; 81.
7 Vennemann MM, Hense HW, Bajanowski T, et al. Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate? J Pediatr 2012; 160: 44-48
8 Mitchell E A, Freemantle J, Young J, Byard R W. POSITION PAPER, Scientific consensus forum to review the evidence underpinning the recommendations of the Australian SIDS and Kids Safe Sleeping Health Promotion Programme – October 2010 Journal of Paediatrics and Child
Health doi:10.1111/j.1440-1754.2011.02215.x