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Contents

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1.	Introduction
2.	Definitions
3.	Background
4.	Responsibilities of the Multi-Disciplinary Workforce
5.	Responsibilities of Core Health Staff
	5.1	In the Community
	5.2	In Hospital
6.	Current Evidence-Based Information to be Provided to All Baby’s Carers
7.	Risk Factors
8.	Reducing the Risks
9.	Using a Cot, Crib or Moses Basket
	9.1	Buying a Cot
	9.2	Using a Second-Hand Cot
	9.3	Moses Baskets/Cribs
	9.4	Travel Cots
	9.5	Mattresses
10.	Car Seats, Pushchairs and Prams
11.	Other Baby Sleep and Carrying Devices
12.	Bedding
13.	Baby Slings
14.	Sleeping Position
15.	Clothing
16.	Dummies
	Appendix 1: Safer Sleeping Legislation Guidelines
	Appendix 2: Risk Assessment Framework for Sudden Infants Death
	Appendix 3: Risk Assessment Tool for Safe Sleeping
	Appendix 4: Bed Sharing
	Appendix 5: Recommended Additional Resources

1. Introduction

This guidance is applicable to the multi-disciplinary workforce who have contact with the parents, carers and relatives of babies. It is to assist practitioners to discuss safe baby sleeping arrangements in order to support parents to make informed choices regarding safer sleep and raise awareness to factors associated with Sudden Infant Death Syndrome (SIDS).

Over 300 babies still die every year as a result of SIDS in the UK (The Lullaby Trust 2016).

The purpose of the guidance is to:

• Provide the multi-disciplinary workforce in Rotherham with clear and consistent evidence-based information;
• Provide workers with the confidence and knowledge to facilitate an open and honest discussion to support baby’s carers to make informed safer sleeping choices for their babies;
• Ensure consistent advice about safer sleeping arrangements is given across Rotherham by all workers.

2. Definitions

For the purpose of this document the following definitions will apply:

SIDS (Sudden Infant Death Syndrome)

Sudden infant death syndrome is defined as the sudden unexpected death of an infant less than 1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and clinical history (Krous, (2004) taken from NICE, (2014)).

Baby's Carer

A parent, grandparent, foster carer/s babysitter or any other person responsible for the baby at that particular time.

Bed-sharing (planned)

Baby’s carers and infant in the same bed for any period of time (day or night) with consideration given to applicable risk factors.

Deaths in infancy

Term relates to deaths of babies under the age of one year.

Co-Sleeping (unplanned)

Baby’s carers and infant sleeping for any period of time, day or night, in close proximity: this can include in a bed, in unconventional sleeping arrangements, on a chair, sofa, bean bag, hammock etc.

Multi-Disciplinary Workforce

Anyone working in Rotherham coming into contact with families who reside in Rotherham

Overlaying

Rolling onto an infant and smothering them in bed or on a chair, sofa or beanbag for example (for more information, see Appendix 1: Safer Sleeping Legislation Guidelines).

SUDI (Sudden Unexpected Death in Infancy)

An acronym used to categorise all sudden unexpected deaths in infancy, this term includes SIDS.

3. Background

Over recent years there has been a significant reduction in infant deaths largely due to an increase in evidence based knowledge and practice. In 2014, 212 babies died of SIDS in the UK: a rate of 0.30 deaths per 1,000 live births. Previous UK data suggests:

• Around half of SIDS babies die while sleeping in a cot or Moses basket;
• Around half of SIDS babies die while co-sleeping. However, 90% of these babies died in hazardous situations which are largely preventable.

If no baby co-slept in hazardous situations, we could potentially reduce co-sleeping SIDS deaths by nearly 90% (UNICEF 2016). In Rotherham we have seen in a reduction in SIDS deaths in line with the national data. Between 2012/13 there were very few deaths in Rotherham from SIDS. However since this time we have seen a rise in deaths.

This guidance has been produced in recognition of the fact that unsafe/hazardous sleeping arrangements are a feature in some infant deaths in Rotherham. Accordingly the emphasis of this document is on safer sleeping arrangements for infants.

4. Responsibilities of the Multi-Disciplinary Workforce

It is the responsibility of the multi-disciplinary workforce to discuss and record, in line with record keeping guidelines of their employing organisation or professional bodies, the information they give to baby’s carers on safer sleeping arrangements at all key contacts.

Information must be provided in such a manner that it is understood by the baby's carer. For those babies' whose carers do not understand English, an approved interpreter should be used where possible and appropriate. Families with other language and communication needs, including learning disabilities, should be offered information in such a way to aid understanding.

Anyone in contact with families should take every opportunity to discuss safer sleeping arrangements for babies and highlight best practice recommendations and risks based on current evidence. This should include safety information that encourages parents to ‘think carefully about their baby’s safety for every sleep’ (ISIS 2015).

5. Responsibilities of Core Health Staff

5.1 In the Community

It is recommended that as a minimum, this information should be discussed and recorded by:

Midwifery Teams:

• During the antenatal period (ideally by 36 weeks):
  • As soon as possible after birth;
  • Prior to discharge from in-patient services.
• During post-natal community visits.

Health Visitor Teams:

• Antenatal contact;
• Primary birth visit;
• Any subsequent follow up contacts.

5.2 In Hospital

All mothers should be encouraged to spend time in skin to skin contact with their new baby in an unhurried environment as soon as possible after birth. Staff should be vigilant in ensuring skin to skin contact is safe and the possibilities of any accidents are minimised. Examples of possible risk exposure includes on ward transfer, after operative birth, after sedative medication, and during extreme tiredness.

All mothers should be encouraged to stay close to their babies whatever their preferred infant feeding choice.

Skin to skin contact is encouraged on the postnatal ward and during the postnatal period, particularly to establish the mother-baby bond, for settling babies, and for babies who are establishing breastfeeding.

In the hospital setting, separation of mother and baby should only occur where the health of either prevents care being offered in the postnatal areas.

Literature consistent with the Safer Sleeping Guidance, on reducing the risk of SUDI, should be given and discussed with all mothers early in the postnatal period.

Advice given should be clearly documented.

The safest place for a baby to sleep whilst in hospital is in a cot by the side of mother’s bed, or a sidecar crib.

If a mother chooses to share her bed with her baby whilst in hospital, to maintain skin to skin contact, for cuddling or feeding her baby, staff should ensure that:

• The benefits, contraindications (see Section 7, Risk Factors) and risk factors for bed sharing are discussed to allow fully informed choice;
• Written information on bed sharing is provided (documentation must be made in the care plan/records that the information has been given discussed and understood);
• The effects of analgesia are discussed and documented.

If the mother makes a fully informed choice to bed share with her baby, all information and care given should be documented. Staff should discuss appropriate sleeping positions (in the case where the mother falls asleep with or without intention). The mother and baby should be monitored by staff as frequently as is practicable.

Effective communication with other members of staff and on hand over of care is essential. Mothers will need to take responsibility for protecting her baby from falling out of the bed/entrapment/overheating. In hospital the bed should always be lowered as far as possible.

In hospital, advise the mother to keep the curtains or door open if taking the baby to bed so that staff can observe if she inadvertently falls asleep whilst bed sharing.

6. Current Evidence-Based Information to be Provided to All Baby’s Carers

In Rotherham we recommend that the safest place for your baby to sleep is in a cot in a room with baby's carer for the first six months.

Please note this refers to any time the baby is asleep during the day or night.

Falling asleep on a sofa, or in a chair, with a baby can be very hazardous and should be avoided at all times (night or day).

Yet, bed-sharing facilitates breastfeeding. Some women may choose to lie down to breastfeed. Breastfeeding mothers often find bed-sharing a positive experience whilst ensuring none of the risk factors below are present (see 4.5.1). Hauck et al (2011) reported that Breastfeeding is protective against SIDS, and this effect is stronger when breastfeeding is exclusive.

7. Risk Factors

Following the updated NICE Guidelines (NICE (2014) Clinical Guideline Addendum 37.1, Routine postnatal care of women and their babies) all practitioners who are in contact with carers with babies should discuss the following with baby's carer:

• There is an association between co-sleeping (on a bed, sofa or chair with an infant) and SIDS;
• The association between co-sleeping (on a bed, sofa or chair with an infant) and SIDS is likely to be greater when they, or their partner, smoke;
• The association between co-sleeping (on a bed, sofa or chair) and SIDS may be greater with:
  • Parental or carer recent alcohol consumption; or
  • Parental or carer drug use; or
  • Low birth-weight or premature infants.

In Rotherham it is recommended that baby's carer/s are advised not to bed-share or co-sleep if any of the following factors are present:

• If anyone sharing the room where baby is sleeping smokes (no matter where or when they smoke);
• If the mother smoked during pregnancy;
• If baby's carer/s have consumed alcohol;
• If baby's carer/s have taken medication or drugs that make them drowsy or sleep more heavily (illegal, prescription or purchased over the counter including anaesthetics after day case or dental surgery);
• Has any illness (physical or mental) or condition that affects awareness of the baby;
• If the baby has a high temperature (then medical advice should be sought);
• If the baby's carer/s has a high temperature;
• If baby's carer/s response to their baby is impaired, for example they are excessively tired or unwell;
• If the baby was small at birth (born before 37 weeks, or weighing less than 2.5 kg at birth);
• Women who chose to exclusively formula feed their baby should be advised that they may not naturally take up a protective sleeping position and this may increase the risk of SIDS.

For more information, see the Safe Sleeping Risks Assessment Tool and the supporting prompt tool to aid staff and carers:

• Appendix 2: Risk Assessment Framework for Sudden Infants Death;
• Appendix 3: Risk Assessment Tool for Safe Sleeping;
• Appendix 4: Bed Sharing.

8. Reducing the Risks

It is in no-one's interest to avoid this discussion with the baby's carer, either on the grounds that it is complex, or to wait until the mother reports that she has already slept with their baby in a bed.

Although many new parents/carers say that they will never sleep with their baby, about 50% of UK babies have bed-shared with a carer during their first three months. It is therefore important that ALL carers have a discussion about bed-sharing/ co- sleeping and consider how they will manage night-time care.

Baby's carers must be advised never to fall asleep on the sofa, chair or beanbag with baby. If baby's carer chooses to sleep anywhere not designed for sleeping with their baby such as the sofa, chair or on a beanbag, they must be alerted to the risk factors associated with this choice. They must also be made aware that adult beds are not designed with infant safety in mind. Babies can die if they get trapped or wedged in the bed or if a baby's carer lies on them. It is the baby's carer's responsibility to make sure the bed environment is as safe as possible for a baby if he or she sleeps there.

If a baby's carer decides to bed-share then they need to make sure that the bed is as safe as possible, with the following guidance:

• The mattress needs to be clean, firm and flat. Soft mattresses and mattress toppers should not be used;
• Do not use waterbeds, electric blankets or bean bags;
• Make sure that baby cannot fall out of bed or get stuck between the mattress and the wall;
• Ensure the floor is clear should baby fall out of bed;
• The room must not be too hot (16 – 20°C is ideal);
• Baby should not be overdressed;
• The baby’s covers must not overheat the baby or cover the baby’s head;
• There is no need for baby to wear a hat in bed. Pillows must be kept away from the baby;
• The baby must not be left alone in or on the bed as even very young babies can wriggle into dangerous positions;
• Any adults in the bed must be made aware that the baby is in the bed;
• If an older child is sleeping in the bed then an adult should sleep between the older child and the baby;
• Avoid overcrowding;
• Avoid having pets or cuddly toys in the bed.

Most mothers who are breastfeeding naturally sleep facing their baby with a body position which protects the baby, for example, stops the baby moving up or down the bed and stops the mother rolling onto her baby.

9. Using a Cot, Crib or Moses Basket

Within Rotherham it is recommended that the safest place for your baby to sleep is in a cot in a room with baby's carer for at least the first six months.

Having the baby sleep (day or night) in a separate room to baby's carer is an established risk factor for SIDS. The multi-disciplinary workforce should advise all baby’s carers to keep baby in the carer’s bedroom at night for at least the first six months, regardless of how the baby is fed.

Guidance for using your cot, crib, Moses basket:

• When an adult is not in the room with baby keep the drop side of the cot up and locked into position;
• Keep the cot away from any furniture which an older baby could use to climb out of the cot;
• Keep the cot away from toiletries and other items such as baby lotion, wipes and nappy sacks which an older baby may be able to reach;
• Avoid curtains and blinds with cords. Dangling cords carry a risk of strangulation. Any present must be securely tied up and placed out of baby’s reach;
• Do not use bumper pads as they are a suffocation hazard for small babies and infants. When baby starts to crawl and climb they may also be used as steps to climb out of the cot;
• When the cot mattress is at its lowest height the top of the rail should be above the baby's chest;
• Cuddly toys (especially large cuddly toys) should be avoided. They could fall on baby causing overheating or accidental smothering;
• Avoid putting the cot/Moses basket next to a window, heater, fire, radiator, lamp or direct sunlight, as it could make the baby too hot.

9.1 Buying a cot

All cots currently sold in the UK should conform to British Safety Standards BS EN 716:2008 (for more information, see National Childbirth Trust website and have a label that states:

• The cot is deep enough to be safe for the baby;
• Cot bars are less than 65mm apart;
• The cot does not have cut outs or steps.

9.2 Using a Second-Hand Cot

Baby’s carers must check that the cot is safe for baby. This includes:

• Points above - (Section 9.1, Buying a Cot);
• If the cot is painted, to strip and re-paint it. There is always a possibility that old paint may have lead in it, see Defra’s leaflet for advice on how to safely strip lead paint;
• Make sure the mattress fits snugly, there should be no corner post or decorative cut-outs in the headboard or foot board which could trap babies limbs;
• It is recommended that a new mattress is used for each child using the cot.

9.3 Moses Baskets/Cribs

The same sleeping advice applies as for cots, keeping the Moses basket/cribs in baby’s carers' room for the first six months.

9.4 Travel Cots

These should be used following manufacturers' instructions. The advice re cots, cribs and Moses basket also applies to use of travel cots.

9.5 Mattresses

Ideally a new mattress should be purchased for each baby. If baby’s carers are using a ‘used’ mattress from a previous child, they should be advised to ensure that it is completely waterproof, has no tears or holes. Ventilated mattresses are not recommended as they are very difficult to keep clean.

A baby should sleep on a firm, flat surface, the use of soft mattresses and toppers is not recommended.

10. Car Seats, Pushchairs and Prams

Car seats, push chairs and prams are not an ideal place for safe sleep in the home. It is important to check on your baby regularly when they are asleep. When they are being transported in a car they should be carried in a properly designed and fitted car seat, facing backwards, and be observed regularly by babies' carer.

On long car journeys stop for regular breaks for air and for drinks for baby (The Lullaby Trust, May 2013), and ensure that baby does not spend longer than necessary in the car seat. It is recommended that after 2 hours babies should be removed from car seats to stimulate and reposition. Therefore regular breaks are also advised when making long car journeys. Extra observation is needed for premature babies who may curl forwards and inwards.

Be careful your baby does not get too hot; remove hats and outdoor clothes when indoors, or in the car (see The Lullaby Trust: Evidence Base (2013)). This advice should be considered when going into shops.

11. Other Baby Sleep and Carrying Devices

These should comply with British safety standards and baby’s parents/carers should be mindful of overheating and the importance of giving the baby room to breathe.

12. Bedding

General advice:

• Baby’s carers need to ensure that the bedding in use is the right size for the cot/crib/Moses basket, as this will prevent the baby getting tangled up;
• Sheets and blankets are ideal. If the baby is too hot a layer can be removed and if too cold a layer added. Cellular blankets should be used (rather than fluffy blankets) but advice should be given about folding cellular blankets (increasing the top rating) and baby wearing appropriate clothing e.g. baby grow/vest;
• The cot should be made up so that the blankets and sheets cover the baby up to his/her chest and tuck under their arms and under the mattress so that the baby lies with their feet at the end of the cot. This is a safe and recommended method as it means it’s difficult for the baby to wriggle down under the bedding;
• Duvets and pillows are not safe for use with babies under one year of age as they could cause overheating and/or increase the risk of accidents from suffocation;
• Do not use cot bumpers: some experts advise avoiding the use of cot bumpers once the baby can sit unaided as they can use the bumper as a means to get out of the cot;
• Some bumpers have strings that attach to the cot. An older child could pull at these strings and become tangled in them;
• Specially designed sleeping bags are useful for babies who are kicking off their blankets. Baby's carers using these must be advised to check that the weight and size of the sleeping bag is right for baby. For example: could use 1 tog in the summer and 2.5 tog in the winter. The sleeping bag should fit snugly around the baby’s chest;
• Do not use extra blankets with sleeping bags and do not use sleeping bags when the baby is in the carers bed;
• Swaddling is suggested as an emerging risk factor for SIDS. Evidence is inconclusive, but baby's carers should be cautious. If they do decide to swaddle their baby, they should be advised not to swaddle above the shoulders or cover the baby's head and only use thin materials. Baby’s temperature should be checked regularly to ensure they are not too hot. Baby can be un-swaddled once they are asleep.

13. Baby Slings

If baby’s carers decide they want to use slings The Consortium of UK Sling Manufacturers and Retailers suggest babies carer's should be advised (ROSPA: Baby Slings):

• To ensure they can see baby's face at all times, they should not have to open a sling to view baby. Baby should be facing upwards and not towards baby's carers body;
• A sling should be tight enough so baby feels securely supported, in their natural position with their tummy and chest close to their carer's body. Baby's carer should be advised they should be able to kiss baby on the head/ forehead simply by tipping their head forward. If the sling is too slack baby will slump down which can hinder their breathing and pull on the back of baby's carer. Baby should not uncurl/ move forward if baby's back is gently pressed;
• If pouch or ring sling is being used baby should be positioned carefully to ensure their bottom is in the deepest part so the sling does not push baby forward so their chin is pressed to their chest;
• Ensure there is always a space of at least a finger width under baby's chin. Baby should never be curled so their chin is forced onto their chest as this restricts their breathing.

14. Sleeping Position

The best sleeping position for a baby – is on their back. Wedges or props should not be used to keep baby in the same position, even though these can be used in Neonatal Units. Eventually babies learn to roll from their back to their front on their own. When this happens, the advice to baby’s carers should still be to put them to sleep on their back, feet to foot of the cot, and not to worry about them moving and leave them to find their own comfortable position (The Lullaby Trust, May 2013).

There is no evidence to suggest that putting twins in the same cot (which is larger than a Moses basket or crib) in the early weeks places them at greater risk of SUDI. However, once the babies can rollover or potentially bang their heads the safer sleeping advice described in this guidance should be followed and they need to be in separate cots (for more information, see Basis: Baby sleep info source - Twins.

15. Clothing

Flame retardant sleepwear is advised. Care should be taken to ensure that suitable clothing is worn for the temperature of the room. Remove bibs before sleep.

16. Dummies

UK Department of Health and Social Care does not recommend dummy use as a way of reducing the risk of SIDS (ISIS, December 2014).

This is a complex issue. It is possible that when dummies are regularly used (when putting baby down to sleep) there is a reduced risk of sudden infant death. However, the evidence base is not strong and not all experts agree.

If baby's carers would prefer to give their baby a dummy, it should be explained that it is advised not to give a dummy until breastfeeding is well established, usually when baby is around one month old, and to gradually withdraw the dummy when they're between six and twelve months old.

Furthermore, The Lullaby Trust (May, 2013) state if a dummy is used it is important to ensure that:

• The use of dummies is consistent within the baby’s sleeping routine;
• A dummy is not forced on the infant or replaced if it falls out once the baby is asleep;
• The dummy does not have any attachments on it;
• The dummy is never coated with something sweet;
• A dummy bought within Europe should conform to European standard EN 1400.

Appendix 1: Safer Sleeping Legislation Guidelines

If you are a person of any age and you:

• Co sleep with a child;
• Not under the influence of any drug/alcohol/or substance;
• Cause his/ her death by suffocation.

The circumstances of the death will be investigated and a report will be made to the coroner to determine the cause of death.

If you are aged 16 years or over and you:

• Co sleep with a child under the age of 3 years;
• Whilst under the influence of drink/alcohol;
• Causing his/her death by suffocation.

You will be liable to criminal prosecution (Wilful Neglect) - Section 1. (2)m Children and Young Persons Act 1933.

If you are a person of any age and you:

• Co-sleep with a child of any age;
• Whilst under the influence of any drug/substance/alcohol;
• Cause his/her death by suffocation.

You will be liable to criminal prosecution (Manslaughter) – Section 5, Offences against the Person Act 1861.

Appendix 2: Risk Assessment Framework for Sudden Infants Death

Click here to view Appendix 2: Risk Assessment Framework for Sudden Infants Death.

Appendix 3: Risk Assessment Tool for Safe Sleeping

Click here to view Appendix 3: Risk Assessment Tool for Safe Sleeping.

Appendix 4: Bed Sharing

Click here to view Appendix 4: Bed Sharing.

Appendix 5: Recommended Additional Resources

Infant Sleep Information Source (ISIS)
ISIS provides information about normal infant sleep based upon the latest UK and world-wide research. ISIS is a collaboration between Durham University, Parent-Infant Sleep Lab, La Leche League, NCT, and UNICEF UK Baby. Friendly Initiative, funded by a grant from the ESRC (Economic and Social Research Council).

Caring for your baby at night - a parent’s guide, UNICEF (UK) Baby Friendly, 2016
This UNICEF Baby Friendly Initiative leaflet, endorsed by the CPHVA, RCM and The Lullaby Trust, is designed to offer helpful, practical advice on coping at night. It covers getting some rest, night feeding, safe sleeping environments and helping baby to settle.

The Health Professionals guide to ‘Caring for your baby at night’, UNICEF (UK) Baby Friendly, 2016
This guide aims to help health professionals who will be using Caring for Your Baby at Night with new parents. It looks at the evidence underpinning the recommendations in the leaflet and offers guidance on discussing these issues.

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