PG40. Safer Sleep Guidance

1.1

The purpose of this guidance is to help staff to give appropriate information and advice to parents to enable them to make an informed choice about safer sleeping arrangements for their babies. The guidance outlines the key risk and protective factors associated with a baby’s sleeping environment which have been identified from national and international research. While there is no advice which guarantees the prevention of Sudden Infant Death Syndrome (SIDS), it is important that parents and carers are informed that the risk can be considerably reduced if the relevant advice is followed.

1.2

It is recognised that carers take their baby into bed to feed, provide comfort and closeness and to settle their baby. Parents who bed share may fall asleep unintentionally. This guideline does not discourage a close and loving bond but does promote strongly recommend that the safest place for a baby to sleep is on their back in a Moses basket, crib or cot in a room with the parent or carer for the first six months (DoH 2009, NICE 2006). This recommendation applies at advice is the same for all times of the day and night when the baby is sleeping, andsleeping and should also be followed whilst in hospital or in any other temporary living situation, (e.g. in hospital, on holiday, staying/moving between family or friends etc).

1.3

There is evidence from long term studies of SUDI suggesting that some infant deaths associated with bed-sharing, co-sleeping and other risk factors could have been avoided.

1.4

For some families, bed sharing is not a choice or indicative of a lack of care, it is a consequence of “bed poverty” – see Barnardo’s – Bed Poverty. It may also occur when a family is living in temporary arrangements e.g. when in temporary accommodation, fleeing domestic violence or on holiday.

For the purposes of this guidance the following definitions apply:

• Bed Poverty is an aspect of child poverty that includes broken or damaged beds, sharing of beds / rooms, sleeping on the floor or inability to wash / dry bedding;
• Bed-sharing describes babies sharing a carer’s bed in hospital or at home, to feed them or to receive comfort. The mother or carer remains awake;
• Co-sleeping describes any one or more person falling asleep with a baby in any environment e.g. sofa, any bed, at any time of day or night;
• Overlying describes rolling onto an infant and smothering them, e.g. in bed (legal definition taken from the Children and Young Persons Act 19393, sections 1 and 2b) or, on a chair, sofa or beanbag.
• SIDS is the sudden infant death syndrome;
• SUDI (sudden unexplained death of an infant), describes the sudden and unexpected death of a baby where a thorough investigation, including a post-mortem, is unable to find a cause of the death;

2.1

The following factors increase the risk of SIDS:

• Smoking is the factor most strongly linked to increased risk of SIDS, during pregnancy and after the baby is born;
• The risk of SIDS is increased when a baby sleeps on a sofa or armchair or in a cot in an unsafe sleeping position or environment i.e. not ‘feet to foot’, not on their back, not in parents’/carers’ bedroom for the first six months etc.
• Inappropriate covers/ toys in the moses basket/ cot;
• Overheated room temperature/wearing a hat.

2.2

All the risks below are specific to sleeping with a baby, i.e. risk to the baby is increased when sleeping with an adult who:

• Smokes;
• Is under the influence of alcohol or drugs – when associated with sleep environment i.e. ‘Don’t sleep in same bed as your baby if you smoke, drink, take drugs or are extremely tired, or if your baby was born prematurely or was of low birth weight;
• If the baby was low birth weight (less than 2.5kg);
• If the baby was premature (born before 37 weeks).Takes prescribed or non-prescription medication or illegal substances such as cannabis that may make them sleep more heavily;
• Has had an anaesthetic, such as after day-care surgery;
• Feels very tired to the point where they would find it difficult to respond to the baby: for example, if they have had less than four hours sleep in the last twenty-four hours.

2.3

The Child Safeguarding Practice Review Panel national review, Out of routine: A Review of Sudden Unexpected Death in Infancy (SUDI) in Families Where the Children are Considered at Risk of Significant Harm (July 2020) highlighted a range predisposing vulnerabilities and risk factors including:

• Parents co-sleeping with babies;
• Parental alcohol or drug use;
• Parental mental ill health;
• Evidence of neglect;
• Domestic abuse;
• Poor housing;
• Parental criminal conviction;
• Parents who were care leavers;
• Young parents.

2.4

Predisposing risks were often combined with out-of-routine incidents, where unexpected changes in family circumstances meant a baby was placed in an unsafe sleep environment, such as:

• A change in accommodation;
• The baby being unwell;
• New partner.

The risk of a parent falling asleep whilst holding a baby, oversleeping or otherwise causing harm to the baby significantly increases if they have been using drugs or alcohol. Causing harm to a baby due to alcohol or drug use may be a criminal offence:

• S.5 Domestic Violence, Crime and Victims Act 2004 created the offence of causing or allowing the death of a child or causing a child to suffer serious physical harm.
• S. 1(2) Children and Young Persons Act 1933 created the offence of overlay of infants under 3 years of age, where a person co sleeps and is under the influence of drink or prohibited drugs.
• S. 1(1) Children and Young Persons Act 1933 created the offence of wilful assault, ill treatment, neglect, abandon or exposes them in a manner likely to cause unnecessary suffering or injury to health.

3.1

The following factors reduce the risk of SIDs:

• Reducing or quitting smoking in pregnancy or after the birth;
• Putting a baby to sleep on their back, with their feet to the bottom of the cot;
• Room sharing (and sleeping in parents’/carers’ bedroom for the first six months) lowers the risk;
• Ensuring the room temperature is between 16-20°c;
• Using a clean, firm, flat, well fitted mattress with secure bedding or well-fitting sleeping bag;
• Avoiding overwrapping baby and keep head uncovered indoors. If parents choose to swaddle their baby this is recommended to be done at every sleep period, as varying this may increase risk. Thin materials should be used and baby’s head not covered.
  • NOTE: in relation to swaddling, the research in this area is not complete. Lullaby Trust say that as all their advice is research based they cannot advise for or against swaddling;
• Breast-feeding;
• Some research suggests, regular use of a dummy can reduce the risk of SIDS, providing this is done consistently every time the baby is put down to sleep.
  • Note: breast-fed babies should not be given a dummy until breast-feeding is established i.e. before they are one month old. See: Lullaby Trust Dummies Factsheet.

3.2

All parents should be informed of the potential risks associated with bed sharing and co-sleeping and the measures that can be taken to reduce risk. Parents should be encouraged to share this advice with anyone else who cares for their baby. It is also important for all parents to be aware of the risks of falling asleep with their infant on a sofa or armchair and to avoid this.

3.3

It is important that all those who work to safeguard and promote the welfare of children are aware of safer sleep guidance and consider how they can support this, for example:

• Providing families with local safer sleep resources or directing to national websites e.g. Lullaby Trust;
• Supporting families to access advice from their midwife or health visitor;
• Display safer sleep leaflets and posters in your setting;
• Providing advice or assistance to families experiencing bed poverty on local resources.

4.1

Some LSCP’s have developed additional guidance and resources in response to local needs in their area. See your LSCP website.

4.2

Additional information can be found here:

• NHS Reduce the Risk of Sudden Infant Death Syndrome (SIDS);
• UNICEF Caring for your Baby at night; A Guide for Parents;
• The Lullaby Trust - A Safer Sleep Guide for Parents;
• The Lullaby Trust - Safer Sleep: Saving Babies Lives A Guide for Professionals;
• NICE Clinical Guidance 37 – Postnatal Care;
• Barnardo’s – Bed Poverty.