Each year, approximately 4,500 infants in this country die in their sleep, from SIDS (sudden infant deaths) or other sleep-related causes. Although some of these deaths can’t be explained, studies have shown that in nearly 90 percent of these cases, the infant was in an unsafe sleep environment, which led to accidental suffocation.
Philadelphia has one of the highest SIDS rates in the country. For the years 2009 and 2010 (the most recent years for which figures are available), a report stated that of the approximate 45 unexpected and sudden infant deaths that occurred, 34 died of accidental suffocation, the equivalent of one preventable death every three weeks. Ten occurred when a person shared a bed with -- and rolled on top of -- an infant; the remaining 24 when the infant’s face was pressed up against an inanimate object in the crib.
The Intensive Care Nursery (ICN) at the Hospital of the University of Pennsylvania started Safe Sleep earlier this year in response to the high incidence -- and risk -- of sleep-related infant deaths, especially in West Philadelphia, some of whom had received care at HUP. “We asked ourselves, ‘What else can we do to keep these infants safe?” said Megan Fulmer, BSN, RN, of the ICN.
The program is based on the recommendations of the American Academy of Pediatrics Safe Sleep Task Force. For example, always place babies supine – on their backs – to sleep. Why is this so important? “When infants sleep prone [on the stomach], they’re rebreathing their breaths, which has less oxygen and more carbon dioxide,” said Michael Posencheg, MD, medical director of the ICN and Newborn Nursery at HUP. “For most babies, it’s not a problem but if babies are at higher risk for SIDS, they may not have an arousal mechanism and will be less likely to react and stir.”
Equally important: The infant should always sleep alone, in a crib, which can be near the parents’ bed but not in bed with them. And all soft bedding, bumpers, stuffed animals or other potential sources of airway obstruction must be kept out of the crib. “Bumpers were created because the space between slats in cribs was wide enough for a baby’s head to get stuck,” Fulmer said. “Now, the distance between slats must be no more than 2-3/8 inches.”
Another important part of HUP’s Safe Sleep program is the use of a “wearable blanket” to replace loose ones, Fulmer said. Two “wings” on either side allow the baby to be securely swaddled, without fear of anything covering the face. Use of the wearable blanket also prevents parents from using multiple blankets, which could cause the baby to become overheated, another risk factor for SIDS. “You should dress your babies in one layer more than you’re comfortably wearing, no more,” Posencheg said. To reduce the risk of SIDS after discharge, the staff gives parents new wearable blankets to bring home with them.
Education is a key component of HUP’s program. The ICN nursing staff receives training on safe sleep guidelines and on the importance of modeling safe sleep for parents. “We need to always model the right behavior so we teach parents the right thing to do. If parents see it being done in the ICN, they’re more likely to do it at home,” Posencheg said. “When parents go home, a grandparent may tell them, it’s ok to put the baby on the stomach and it’s ok to sleep with the baby. We are breaking a culture.”
Educating parents is essential as well. “A mandatory part of discharge is for family members to watch our safe sleep video provided by the National Institutes of Health,” Fulmer said. “We also have in-depth conversations with them, about how important it is, how it benefits the baby.”
The program’s impact has been significant. Compliance to safe sleep practices among the ICN nursing staff improved within the first few weeks of starting the program, remaining above 90 percent since late January. (Fulmer noted that in some cases – for example, if the infant has specific respiratory problems or certain types of reflux -- following all the guidelines could interfere with medical care.)
And surveying former parents who received the safe sleep education showed that all put their newborns to bed on their backs, a 100 percent increase over pre-implementation rates.
HUP’s Safe Sleep Program is the first of its kind in the city.
“We surveyed ICN staff in other hospitals and they all put the babies to sleep on their backs but we needed more,” Fulmer said. With the success of its ICN program, the staff is now working to implement the program in the well-baby unit and, ultimately, attain the Safe Sleep Hospital certification through the Cribs for Kids Foundation. This recognition demonstrates a commitment to reducing infant Sleep-Related Deaths by promoting best safe sleep practices and by educating on infant sleep safety.
The ICN staff is also working with their counterparts at Pennsylvania Hospital to start the program. “We want to eventually spread the initiative to all hospitals within Penn Medicine,” Fulmer said.