In 1992, the AAP began recommending babies sleep on their backs to prevent suffocation and sudden infant death syndrome (SIDS). Since this recommendation, the number of infant deaths has dropped more than 50 percent in the United States. Yet the number of infant deaths from suffocation or entrapment during sleep has increased.
Since 2005, the American Academy of Pediatrics (AAP) has made several changes to its recommendations for safe sleep.
Recently, the AAP issued more specific recommendations for safer sleep, including eliminating positioning devices, such as wedges, from cribs, as well as bumper pads, although some retail stores still sell these.
Joining the show to discuss the new recommendations from the AAP to make babies as safe as possible in their sleep environment, is F. Sessions Cole, MD and Andrea Coverstone, MD.
Best Practices on Infant Sleep Safety
Featured Speakers:
Learn more about F. Sessions Cole, MD
Dr. Coverstone is an Assistant Professor of Pediatrics within the Division of Allergy, Immunology and Pulmonary Medicine. She graduated from Gonzaga University in Spokane, WA in 2004 with a Bachelor’s of Science in Biology. She went on to receive her medical degree from Saint Louis University School of Medicine and completed her internship and residency in pediatrics at the University of North Carolina in Chapel Hill (2009-2012).
Learn more about Andrea Coverstone, MD
F. Sessions Cole, MD | Andrea Coverstone, MD
Washington University physician F. Sessions Cole, MD, assistant vice chancellor for children’s health, division chief of newborn medicine, and chief medical officer at St. Louis Children’s Hospital.Learn more about F. Sessions Cole, MD
Dr. Coverstone is an Assistant Professor of Pediatrics within the Division of Allergy, Immunology and Pulmonary Medicine. She graduated from Gonzaga University in Spokane, WA in 2004 with a Bachelor’s of Science in Biology. She went on to receive her medical degree from Saint Louis University School of Medicine and completed her internship and residency in pediatrics at the University of North Carolina in Chapel Hill (2009-2012).
Learn more about Andrea Coverstone, MD
Transcription:
Best Practices on Infant Sleep Safety
Melanie Cole (Host): In 1992, the AAP began recommending babies sleep on their backs to prevent suffocation and Sudden Infant Death Syndrome. Since this recommendation, the number of infant deaths has dropped more than 50% in the United States. Since 2005, the American Academy of Pediatrics, has made several changes to its recommendation for safe sleep. My guests today are Dr. F. Sessions Cole. He’s a Washington University physician, assistant vice chancellor for Children’s Health, division chief of newborn medicine and chief medical officer at St. Louis Children’s Hospital and Dr. Andrea Coverstone. She’s a Washington University pediatric pulmonary medicine physician at St. Louis Children’s Hospital. Welcome to the show doctors. Dr. Cole, I would like to start with you. Tell us a little bit about the evolution of safe sleep. We used to just put kids in on their tummy. What’s different now?
Dr. F. Sessions Cole, MD (Guest): Well, what’s different now is that we understand that the position that a baby is put to bed in, has a significant impact on the risk that the baby will suffer some kind of unexplained death during sleep. And this was all really brought to light back in the mid-1990s with a series of large scale studies that indicated that children who go to sleep on their stomachs are at increased risk of death during sleep. And so, since that time, the American Academy of Pediatrics has had a consistent campaign to educate parents, grandparents and anyone who is putting a baby to sleep including for example, day care centers, where babies also sleep; to be sure that they understand that the best position for a baby during sleep is on her or his back.
Melanie: Dr. Coverstone, so speak about the recent AAP recommendations on safe sleep and what’s changed now?
Andrea Coverstone, MD (Guest): Yes, so as Dr. Cole had mentioned, we primarily have been focusing on back to sleep but the American Academy of Pediatrics has recognized that there are other modifiable risk factors that puts a baby at increased risk of dying during sleep. So, the AAP has recently, in the past year put out new recommendations that talk about the sleep environment itself. So, it’s more than just about the baby’s sleeping on its back; but it also has to do with the sleep environment. So, ensuring that the place that the baby sleeps is appropriate, that it is a firm bedding, that it is free from stuffed animals or blankets or pillows that the baby might suffocate within, that the baby is kept near the parent but not necessarily bedsharing which is another discussion, but near the parent and we promote other things such as breast feeding, use of pacifiers and other like I said, modifiable things that parents can do to ensure that the baby is in the safest way sleeping to lower that risk of sudden infant death.
Melanie: Dr. Cole, speak about some of the common myths about safe sleep and people think about swaddling and Dr. Coverstone mentioned co-sleeping, bedsharing. So, what have you seen going on out there. Break up some of those myths for us.
Dr. Cole: Well one of myths is that babies may vomit during sleep and may suffocate due to the vomiting and that myth is clearly not true. While babies may have some wet burps, both when they are awake and when they are asleep. Even babies with wet burps or the medical term is called gastroesophageal reflux where breast milk or formula comes out of the stomach between feedings up into the mouth of the baby. Even babies with that problem should sleep on their backs not on their stomachs. In addition, in terms of other myths, it is important to understand that babies need to sleep as Dr. Coverstone indicated, on a firm sleep surface, a crib, a bassinet, a portable crib or play yard that should meet all the safety standards of the consumer product safety commission is what is recommended with a tight-fitting firm mattress and fitted sheet design for that particular sleep surface. I know that many parents would love to have a baby “be comfortable” by sleeping in a soft bed; but there is no question that that is a myth. That the safest place for a baby is on a firm sleep surface and not on a surface where there are a lot of covers or toys or other things that might get in the way of a baby sleeping.
Finally, I would like to be sure that everyone understands that moms and dads can reduce the risk of any kind of harm during sleep to their baby if they don’t smoke. Smoking is a – I know grammy may have smoked during the pregnancy or auntie may have smoked during the pregnancy or after the pregnancy; but smoking during pregnancy or exposure to second hand smoke definitely increases the risk of death during sleep and therefore it is important to keep every home, every car, where a baby is sleeping and breathing free of tobacco smoke.
Melanie: Dr. Cole, along those lines, what about crib bumpers? Because people don’t – they worry about the slats in the bars of the cribs and as you said, they want their children to be cozy in the crib and bumpers are so cute with the little bears on them and such. Are we allowed to use those or it that off limits as well?
Dr. Cole: It’s important for everyone to understand that cribs now must satisfy a number of consumer product safety commission standards and among those standards is that the baby will not be able to get her or his head stuck between the slats in the cribs. Therefore, there is no need to attach any kind of object like that, loose bedding etc. to a crib. It’s very important that a baby sleep in a crib that’s as free of bumpers and other potential soft objects as possible.
Melanie: Dr. Coverstone, what about swaddling, so you put your baby on their back and they are swaddled and if they start to come out of that swaddle then the blanket is in there. What do you tell pediatricians to tell their parents when they ask this question?
Dr. Coverstone: Yeah, that’s a very good question. So, swaddling is personal choice. Some people feel that it is beneficial for their baby to sleep when it is swaddled because the baby feels comfortable. But there are a couple of things to keep in mind when it comes to swaddling. One of the risk factors for sudden infant death is we think increases in body temperature. So, a baby should be kept really no more than one extra layer of clothing is what we would advise parents and physicians to tell families is that what you might wear to bed, the baby should be in such an item with one extra layer. So that might include an extra onesie underneath a pajama or a swaddle. And swaddling is safe in the beginning period, but must be appropriately attached to the baby and you don’t want anything covering the baby’s head and the thing to keep in mind is once the baby is starting to show signs that he or she is rolling over or might roll over, which can happen around three to four or five months of age; that baby should no longer have arms tucked in and swaddled because that certainly can increase the risk if the baby goes from a back position to a front position without having his or her arms available to move him back. That being said, once a baby is able to roll forward and back, the recommendations are that you can leave him in that position. So, you always place the baby on his or her back to sleep but if he is old enough to flip himself onto his belly, it is okay to leave him or her in that position.
Melanie: And you answered my question before I even asked it. Because parents do ask, should I run in there ten times a night and roll them back on their back. So, you are saying it is okay to leave them if they are able to roll around themselves?
Dr. Coverstone: That’s correct.
Melanie: Dr. Coverstone, what do you want the listeners to know about room sharing and the new recommendations by the AAP?
Dr. Coverstone: So, one of the biggest changes to these recommendations that the AAP put out recently, is that they are now recommending that babies sleep in the same room as the parent for the first six months of life, at least the first six months of life up to one year. And what’s important to know is that what the AAP is advocating for is room sharing but not bed sharing. So, a baby’s risk of sudden infant death is decreased when the baby is nearby the parents because it is in a close observation but probably also promotes some breastfeeding in those individuals who choose to breastfeed, and we know that breastfeeding is protective for SIDS, but again, it’s important to know what they are not advocating is bed sharing. Because as we know, there is much evidence to suggest that a baby who shares a bed with a parent is at a significantly increased risk of dying during sleep particularly if that parent is under the influence of alcohol or medications, if they are a smoker, if the baby is younger than four months of age or there is any high-risk bed setup. So, pillows in the bed or soft bedding.
Melanie: So, Dr. Cole, what initiatives are you implementing that support these positions?
Dr. Cole: Well it is very important that parents and grandparents or anyone who is going to be caring for a baby, understand the importance of these new AAP recommendations and so we try to begin the education about safe sleep in the last trimester of pregnancy by sharing through our obstetrical colleagues or our nurse midwives or general practitioners the safe sleep habits that a mom a dad or a family needs to be aware of around putting a baby to sleep. In addition, after the delivery, we are very enthusiastic about being sure that mom and her family understand the specifics of safe sleep during the immediate post-partum period and there are some institutions around the country who are providing moms who don’t have much in the way of resources with the best sleeping environment that is to say a solid surface for the baby to sleep on that she can take home. We are very anxious also in collaboration with our primary care colleagues in pediatrics, to be sure that these messages about safe sleep are reinforced during the first several weeks and several months of primary care follow-up and finally, we urge moms both before birth and after birth to breast feed because babies who are breastfed have a lower risk of SIDS.
Melanie: Dr. Coverstone, as you are doing these things to educate staff on these initiatives and patients and families; what are you doing to advocate safe sleep when patients are discharged, vouchers, halo sleep sets, and that sort of thing?
Dr. Coverstone: Sure. So, we have a program here where we can get access to swaddlers and safe swaddlers for families and so we start at discharge with education and I have worked with our nurses on several of the pulmonary floors on our unit as well as we have a nurse practitioner that is working hospital-wide on providing resources to family and providing education to family so that they understand the risks that are involved or that a child may have if they don’t take the proper measures about ensuring the environment is safe in the home. I think sometimes families can be falsely reassured when their child is in the hospital because the child may or may not be hooked up to several monitors, but the reality is when we go home; these children are not on monitors and it’s not recommended to continue to have them on monitors in an otherwise healthy infant and we have to make sure we take other measures. So, we do provide sleep sacks for families and provide educational resources for families before they are discharged.
Melanie: Dr. Cole, last word to you. What does all this mean for referring pediatricians? What else would you like them to know and what else would you like their patients and families to know about safe sleep initiatives at St. Louis Children’s Hospital and around the country from the American Academy of Pediatrics?
Dr. Cole: Well it’s important for families and for pediatricians to know that we have terrific resources here to help answer any questions that the pediatrician or the family might have about the safest possible sleep environment and sleep habits for babies. We want to be sure that pediatricians understand that we completely support the recommendations of the American Academy of Pediatrics locally and also nationally that many of our physicians here at St. Louis Children’s Hospital have been involved in the development of those and review of those recommendations and we are anxious to continue to see a decrease in the number of babies who die in the first six months of life with sudden infant death syndrome or sudden unexpected death syndrome thanks to the continued collaboration with our primary care pediatric colleagues and with families who are putting their babies to sleep.
Melanie: Thank you so much doctors for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for listening.
Best Practices on Infant Sleep Safety
Melanie Cole (Host): In 1992, the AAP began recommending babies sleep on their backs to prevent suffocation and Sudden Infant Death Syndrome. Since this recommendation, the number of infant deaths has dropped more than 50% in the United States. Since 2005, the American Academy of Pediatrics, has made several changes to its recommendation for safe sleep. My guests today are Dr. F. Sessions Cole. He’s a Washington University physician, assistant vice chancellor for Children’s Health, division chief of newborn medicine and chief medical officer at St. Louis Children’s Hospital and Dr. Andrea Coverstone. She’s a Washington University pediatric pulmonary medicine physician at St. Louis Children’s Hospital. Welcome to the show doctors. Dr. Cole, I would like to start with you. Tell us a little bit about the evolution of safe sleep. We used to just put kids in on their tummy. What’s different now?
Dr. F. Sessions Cole, MD (Guest): Well, what’s different now is that we understand that the position that a baby is put to bed in, has a significant impact on the risk that the baby will suffer some kind of unexplained death during sleep. And this was all really brought to light back in the mid-1990s with a series of large scale studies that indicated that children who go to sleep on their stomachs are at increased risk of death during sleep. And so, since that time, the American Academy of Pediatrics has had a consistent campaign to educate parents, grandparents and anyone who is putting a baby to sleep including for example, day care centers, where babies also sleep; to be sure that they understand that the best position for a baby during sleep is on her or his back.
Melanie: Dr. Coverstone, so speak about the recent AAP recommendations on safe sleep and what’s changed now?
Andrea Coverstone, MD (Guest): Yes, so as Dr. Cole had mentioned, we primarily have been focusing on back to sleep but the American Academy of Pediatrics has recognized that there are other modifiable risk factors that puts a baby at increased risk of dying during sleep. So, the AAP has recently, in the past year put out new recommendations that talk about the sleep environment itself. So, it’s more than just about the baby’s sleeping on its back; but it also has to do with the sleep environment. So, ensuring that the place that the baby sleeps is appropriate, that it is a firm bedding, that it is free from stuffed animals or blankets or pillows that the baby might suffocate within, that the baby is kept near the parent but not necessarily bedsharing which is another discussion, but near the parent and we promote other things such as breast feeding, use of pacifiers and other like I said, modifiable things that parents can do to ensure that the baby is in the safest way sleeping to lower that risk of sudden infant death.
Melanie: Dr. Cole, speak about some of the common myths about safe sleep and people think about swaddling and Dr. Coverstone mentioned co-sleeping, bedsharing. So, what have you seen going on out there. Break up some of those myths for us.
Dr. Cole: Well one of myths is that babies may vomit during sleep and may suffocate due to the vomiting and that myth is clearly not true. While babies may have some wet burps, both when they are awake and when they are asleep. Even babies with wet burps or the medical term is called gastroesophageal reflux where breast milk or formula comes out of the stomach between feedings up into the mouth of the baby. Even babies with that problem should sleep on their backs not on their stomachs. In addition, in terms of other myths, it is important to understand that babies need to sleep as Dr. Coverstone indicated, on a firm sleep surface, a crib, a bassinet, a portable crib or play yard that should meet all the safety standards of the consumer product safety commission is what is recommended with a tight-fitting firm mattress and fitted sheet design for that particular sleep surface. I know that many parents would love to have a baby “be comfortable” by sleeping in a soft bed; but there is no question that that is a myth. That the safest place for a baby is on a firm sleep surface and not on a surface where there are a lot of covers or toys or other things that might get in the way of a baby sleeping.
Finally, I would like to be sure that everyone understands that moms and dads can reduce the risk of any kind of harm during sleep to their baby if they don’t smoke. Smoking is a – I know grammy may have smoked during the pregnancy or auntie may have smoked during the pregnancy or after the pregnancy; but smoking during pregnancy or exposure to second hand smoke definitely increases the risk of death during sleep and therefore it is important to keep every home, every car, where a baby is sleeping and breathing free of tobacco smoke.
Melanie: Dr. Cole, along those lines, what about crib bumpers? Because people don’t – they worry about the slats in the bars of the cribs and as you said, they want their children to be cozy in the crib and bumpers are so cute with the little bears on them and such. Are we allowed to use those or it that off limits as well?
Dr. Cole: It’s important for everyone to understand that cribs now must satisfy a number of consumer product safety commission standards and among those standards is that the baby will not be able to get her or his head stuck between the slats in the cribs. Therefore, there is no need to attach any kind of object like that, loose bedding etc. to a crib. It’s very important that a baby sleep in a crib that’s as free of bumpers and other potential soft objects as possible.
Melanie: Dr. Coverstone, what about swaddling, so you put your baby on their back and they are swaddled and if they start to come out of that swaddle then the blanket is in there. What do you tell pediatricians to tell their parents when they ask this question?
Dr. Coverstone: Yeah, that’s a very good question. So, swaddling is personal choice. Some people feel that it is beneficial for their baby to sleep when it is swaddled because the baby feels comfortable. But there are a couple of things to keep in mind when it comes to swaddling. One of the risk factors for sudden infant death is we think increases in body temperature. So, a baby should be kept really no more than one extra layer of clothing is what we would advise parents and physicians to tell families is that what you might wear to bed, the baby should be in such an item with one extra layer. So that might include an extra onesie underneath a pajama or a swaddle. And swaddling is safe in the beginning period, but must be appropriately attached to the baby and you don’t want anything covering the baby’s head and the thing to keep in mind is once the baby is starting to show signs that he or she is rolling over or might roll over, which can happen around three to four or five months of age; that baby should no longer have arms tucked in and swaddled because that certainly can increase the risk if the baby goes from a back position to a front position without having his or her arms available to move him back. That being said, once a baby is able to roll forward and back, the recommendations are that you can leave him in that position. So, you always place the baby on his or her back to sleep but if he is old enough to flip himself onto his belly, it is okay to leave him or her in that position.
Melanie: And you answered my question before I even asked it. Because parents do ask, should I run in there ten times a night and roll them back on their back. So, you are saying it is okay to leave them if they are able to roll around themselves?
Dr. Coverstone: That’s correct.
Melanie: Dr. Coverstone, what do you want the listeners to know about room sharing and the new recommendations by the AAP?
Dr. Coverstone: So, one of the biggest changes to these recommendations that the AAP put out recently, is that they are now recommending that babies sleep in the same room as the parent for the first six months of life, at least the first six months of life up to one year. And what’s important to know is that what the AAP is advocating for is room sharing but not bed sharing. So, a baby’s risk of sudden infant death is decreased when the baby is nearby the parents because it is in a close observation but probably also promotes some breastfeeding in those individuals who choose to breastfeed, and we know that breastfeeding is protective for SIDS, but again, it’s important to know what they are not advocating is bed sharing. Because as we know, there is much evidence to suggest that a baby who shares a bed with a parent is at a significantly increased risk of dying during sleep particularly if that parent is under the influence of alcohol or medications, if they are a smoker, if the baby is younger than four months of age or there is any high-risk bed setup. So, pillows in the bed or soft bedding.
Melanie: So, Dr. Cole, what initiatives are you implementing that support these positions?
Dr. Cole: Well it is very important that parents and grandparents or anyone who is going to be caring for a baby, understand the importance of these new AAP recommendations and so we try to begin the education about safe sleep in the last trimester of pregnancy by sharing through our obstetrical colleagues or our nurse midwives or general practitioners the safe sleep habits that a mom a dad or a family needs to be aware of around putting a baby to sleep. In addition, after the delivery, we are very enthusiastic about being sure that mom and her family understand the specifics of safe sleep during the immediate post-partum period and there are some institutions around the country who are providing moms who don’t have much in the way of resources with the best sleeping environment that is to say a solid surface for the baby to sleep on that she can take home. We are very anxious also in collaboration with our primary care colleagues in pediatrics, to be sure that these messages about safe sleep are reinforced during the first several weeks and several months of primary care follow-up and finally, we urge moms both before birth and after birth to breast feed because babies who are breastfed have a lower risk of SIDS.
Melanie: Dr. Coverstone, as you are doing these things to educate staff on these initiatives and patients and families; what are you doing to advocate safe sleep when patients are discharged, vouchers, halo sleep sets, and that sort of thing?
Dr. Coverstone: Sure. So, we have a program here where we can get access to swaddlers and safe swaddlers for families and so we start at discharge with education and I have worked with our nurses on several of the pulmonary floors on our unit as well as we have a nurse practitioner that is working hospital-wide on providing resources to family and providing education to family so that they understand the risks that are involved or that a child may have if they don’t take the proper measures about ensuring the environment is safe in the home. I think sometimes families can be falsely reassured when their child is in the hospital because the child may or may not be hooked up to several monitors, but the reality is when we go home; these children are not on monitors and it’s not recommended to continue to have them on monitors in an otherwise healthy infant and we have to make sure we take other measures. So, we do provide sleep sacks for families and provide educational resources for families before they are discharged.
Melanie: Dr. Cole, last word to you. What does all this mean for referring pediatricians? What else would you like them to know and what else would you like their patients and families to know about safe sleep initiatives at St. Louis Children’s Hospital and around the country from the American Academy of Pediatrics?
Dr. Cole: Well it’s important for families and for pediatricians to know that we have terrific resources here to help answer any questions that the pediatrician or the family might have about the safest possible sleep environment and sleep habits for babies. We want to be sure that pediatricians understand that we completely support the recommendations of the American Academy of Pediatrics locally and also nationally that many of our physicians here at St. Louis Children’s Hospital have been involved in the development of those and review of those recommendations and we are anxious to continue to see a decrease in the number of babies who die in the first six months of life with sudden infant death syndrome or sudden unexpected death syndrome thanks to the continued collaboration with our primary care pediatric colleagues and with families who are putting their babies to sleep.
Melanie: Thank you so much doctors for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for listening.