CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Transition to a Safe Home SleepEnvironment for the NICU PatientMichael H. Goodstein, MD, FAAP,a,b Dan L. Stewart, MD, FAAP,c Erin L. Keels, DNP, APRN-CNP, NNP-BC,d,e

Rachel Y. Moon, MD, FAAP,f COMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDEN INFANT DEATH SYNDROME

Of the nearly 3.8 million infants born in the United States in 2018, 8.3%had low birth weight (ie, weight <2500 g) and 10% were born preterm(ie, gestational age of <37 weeks). Ten to fifteen percent of infants(approximately 500000 annually), including low birth weight andpreterm infants and others with congenital anomalies, perinatallyacquired infections, and other diseases, require admission to a NICU.Every year, approximately 3600 infants in the United States die ofsudden unexpected infant death (SUID), including sudden infant deathsyndrome (SIDS), unknown and undetermined causes, and accidentalsuffocation and strangulation in an unsafe sleep environment. Pretermand low birth weight infants are 2 to 3 times more likely than healthyterm infants to die suddenly and unexpectedly. Thus, it is importantthat health care professionals prepare families to maintain their infantin a safe home sleep environment as per recommendations of theAmerican Academy of Pediatrics. Medical needs of the NICU infant oftenrequire practices such as nonsupine positioning, which should betransitioned as soon as medically possible and well before hospitaldischarge to sleep practices that are safe and appropriate for thehome environment. This clinical report outlines the establishment ofappropriate NICU protocols for the timely transition of these infantsto a safe home sleep environment. The rationale for theserecommendations is discussed in the accompanying technical report“Transition to a Safe Home Sleep Environment for the NICU Patient,”included in this issue of Pediatrics.

INTRODUCTION

Sudden unexpected infant death (SUID), including sudden infant deathsyndrome (SIDS), is the leading cause of postneonatal mortality in theUnited States. In up to 95% of these cases, there are one or moreenvironmental risk factors identified.1 Preterm and low birth weightinfants are 2 to 3 times more likely than healthy term infants to die

abstractaDivision of Newborn Services, WellSpan Health, York, Pennsylvania;bDepartment of Pediatrics, College of Medicine, The Pennsylvania StateUniversity, Hershey, Pennsylvania; cDepartment of Pediatrics, NortonChildren’s and School of Medicine, University of Louisville, Louisville,Kentucky; dNational Association of Neonatal Nurse Practitioners,National Association of Neonatal Nurses, Chicago, Illinois; eNeonatalAdvanced Practice, Nationwide Children’s Hospital, Columbus, Ohio; andfDivision of General Pediatrics, School of Medicine, University ofVirginia, Charlottesville, Virginia

Drs Goodstein and Stewart conceptualized, conducted the literaturesearch, wrote and revised the manuscript, and considered input from allreviewers and the board of directors; Dr Keels conducted the literaturesearch, wrote and revised the manuscript, and considered input from allreviewers and the board of directors; Dr Moon conceptualized andrevised the manuscript and considered input from all reviewers and theboard of directors; and all authors approved the final manuscript assubmitted and take responsibility for the final publication.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors havefiled conflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, clinical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons orthe organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations,taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

To cite: Goodstein MH, Stewart DL, Keels EL, et al; AAPCOMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDENINFANT DEATH SYNDROME. Transition to a Safe Home SleepEnvironment for the NICU Patient. Pediatrics.2021;148(1):e2021052045

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suddenly and unexpectedly,2,3 so itis particularly important to model asafe home sleep environment in theNICU before a neonate is dischargedfrom the hospital. The AmericanAcademy of Pediatrics (AAP),through the Committee on Fetus andNewborn, has recommended since2008 that preterm infants betransitioned to a predominantlysupine position by a postmenstrualage of 32 weeks to promote safesleep, a recommendation supportedby the AAP Task Force on SuddenInfant Death Syndrome (henceforth,“task force”).2,4,5 Because therecommendations for infant sleepsafety at home also include otherpostnatal environmental factors (eg,use of a firm, flat sleep surface,avoidance of loose bedding or softobjects, a neutral thermalenvironment, room sharing withoutbed sharing, smoke-freeenvironment), safe sleeprecommendations for NICU patientsshould also address these factors.Recognizing that not all infants areready for such a sleep environmentby 32 weeks’ postmenstrual age, thetask force recommends transitioningthe infant to the safe home sleeppractices as soon as he or she ismedically stable and significantlybefore the anticipated dischargefrom the hospital.4

Studies have shown that NICUproviders do not consistentlysupport infant sleep safetyrecommendations.5–7 Researchers ina 2016 study of 96 NICU nursesfound that only 53% strongly agreedthat safe sleep recommendationsmake a difference in preventingSIDS, and only 20% strongly agreedthat parents would model nurses’behaviors at home.7 However,research from the well-babynursery, community settings, andthe NICU demonstrate that safesleep education and modeling inthese sites translate into increased

knowledge and improved safe sleeppractices among new parents.8–11

This clinical report reviews theevidence for common NICU sleeppractices and provides guidance fortransitioning the infant to a sleepenvironment that is safe andappropriate for the homeenvironment.

SLEEP POSITION

Since 1992, back sleeping has beenrecommended for the reduction ofsleep-related deaths. Thisrecommendation, in conjunctionwith the Back to Sleep campaign in1994, resulted in SIDS rates in theUnited States decreasing by 53% by1999.12 Prone and side sleeppositions are associated with anincreased risk of SIDS, and neitherare recommended.4 The risk of SIDSfor preterm and low birth weightinfants in the prone position ispotentially greater than that ofhealthy term infants.4,13 However,there are a number of scenarios inthe NICU in which nonsupinepositioning is applied for potentialtherapeutic benefit. Nonsupinepositioning in the NICU in all casescan be used as a teachable momentwith the family regarding eventualreadiness for safe infant sleeppositioning and environment.

Respiratory Distress and ChronicLung Disease

Prone positioning is commonly usedin infants with both acute andchronic respiratory distress.Preterm infants in the proneposition have improved oxygenationand pulmonary function, includingdynamic lung compliance and tidalvolume, as well as lessintrapulmonary shunting andimproved thoraco-abdominalsynchrony.14–16 In the supineposition, some lung tissue isdependent to the heart andmediastinal structures, increasingpotential for atelectasis. In addition,

in the supine position, abdominalcontents may limit ventilationthrough opposition to the excursionof the diaphragm.14,17 A Cochranereview of positioning for acuterespiratory distress in infants andchildren found small but statisticallysignificant improvements inoxygenation and tachypnea withprone positioning.18 The benefit ofprone positioning during the acutephase of respiratory disease (wheninfants are closely monitored) mayoutweigh the importance ofmodeling safe sleep positioning inthe extremely preterm infant.

Data are more limited regardingpotential benefits of pronepositioning in the preterm infantwith evolving chronic lung disease.The studies are small and haveshown conflicting results.19–23 Onestudy found higher oxygensaturations and functional residualcapacity in the prone position butno difference in compliance orresistance in oxygen-dependentinfants.19 Another study foundprone positioning increased tidalvolumes and minute ventilation butalso increased work of breathing.22

Although undefined, at some pointthe diminishing benefits of pronepositioning are outweighed by theconcern of reinforcing a sleepposition that increases the risk ofSUID.

Airway Abnormalities

Although uncommon, there arecongenital airway abnormalities thatresult in respiratory compromise,and some infants with theseconditions may benefit from pronepositioning. The benefit of pronepositioning is particularly relevantin Pierre Robin sequence, in whichthere is gravity-dependent tongue-based obstruction.24 Althoughinfants with mild cases of PierreRobin sequence will be stablesleeping supine and infants withsevere cases will have early surgical

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intervention, intermediate casesmay be more challenging andachieve relief with prone positioninguntil they outgrow their airwayobstruction.

Apnea of Prematurity

Some studies have suggested thatthe frequency and severity of apneaof prematurity may be decreasedthrough prone positioning, but thesestudies showed mild benefit andwere limited by small samplesize.25,26 More recent studies havedisputed this conclusion.27,28 A 2017Cochrane review found no statisticaldifferences in apnea, bradycardia, oroxygen saturations and concludedthat body position was not relevantto controlling apnea frequency.29

Nonsupine positioning should not beused as a strategy to decrease apneaof prematurity.

Gastroesophageal Reflux

Positioning has often been toutedas a treatment ofgastroesophageal reflux disease(GERD), but the risk of suddenunexpected death has decreasedenthusiasm for this strategy. TheAAP agrees with therecommendation of both the NorthAmerican Society for PediatricGastroenterology, Hepatology andNutrition and the EuropeanSociety for PediatricGastroenterology, Hepatology andNutrition “not to use positionaltherapy (ie, head elevation,elevation of the head of the crib,lateral and prone positioning) totreat symptoms of GERD insleeping infants.”30 Studies havesuggested less reflux when theinfant is in the prone positionversus the supine position, so it isacceptable to place an awakeinfant prone after feeding if theinfant is continuouslymonitored.31,32 Although gastricemptying may be improved byplacing the infant in the rightlateral position, some studies have

demonstrated that when preterminfants are placed in the leftlateral position after feeding,there is a decrease in the numberof transient relaxations of thelower esophageal sphincter.32–35

However, infants should not beplaced in an inclined or nonsupineposition for sleep as treatment ofGERD.

Hyperbilirubinemia

Prone positioning is sometimesused in alternation with supinepositioning while infants are beingtreated with phototherapy forhyperbilirubinemia. However, asystematic review found supinepositioning was equally effectiveto periodically turning infants.36

The National Institute for Healthand Clinical Excellence (NICE) inthe United Kingdom stated thatpositioning has no significantinfluence on the mean change inserum bilirubin concentration orthe duration of phototherapy forinfants born at term.37 As such,the NICE recommends infants beplaced in the supine positionwhile being treated withphototherapy to ensure consistentadvice about SIDS risk.37 Since theNICE recommendation, a study ofinfants born at $33 weeks’gestation compared supine withalternating positioning and foundidentical rates of decrease in totalserum bilirubin concentration at12 and 24 hours after initiation ofphototherapy.38 The consistencyof the results in both term andpreterm infants confirm thatbarring another medical conditionrequiring prone position,hyperbilirubinemia should betreated routinely in the supineposition.

Neonatal Opioid WithdrawalSyndrome

The infant with neonatal opioidwithdrawal syndrome (NOWS) isgenerally treated with supportive,

nonpharmacologic care designed tominimize stimulation and to supportthe infant’s self-regulation.39,40 Inone study, prone positioning wasassociated with decreased severityof NOWS scores and reduced caloricintake.41 Although prone positioningmay be useful for monitoredinpatients during the acutewithdrawal phase of NOWS, itshould be discontinued whenpossible and before hospitaldischarge to decrease SUID risk.

BEDDING AND POSITIONERS

Per AAP recommendations, infantsat home should be placed on a flat,firm sleep surface (ie, crib,bassinet, portable crib, or playyard that conforms to the safetystandards of the ConsumerProduct Safety Commission)2,42,43

covered by a fitted sheet with noother bedding. Because softbedding and loose objects in thesleep environment can obstructthe infant’s airway, increasing therisk of rebreathing, SIDS, andsuffocation,44–52 these itemsshould not be in the sleepenvironment. Although beddingand positioners are often used fordevelopmentally sensitive careand for treatment ofplagiocephaly, these items shouldbe removed from the sleepenvironment.

Developmentally Sensitive Care

Developmentally sensitive care is animportant therapeutic interventionfor preterm and other ill infants.However, because such care oftenmay be inconsistent with provisionsfor a safe infant home sleepenvironment, staff should usedemonstration of these techniquesas a teachable moment with thefamily regarding eventual readinessfor safe infant sleep positioning andenvironment.

Developmentally sensitive carerefers to a broad category of

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interventions designed to minimizethe stress of the extrauterineenvironment and optimize thephysical and neurodevelopmentaloutcomes for preterm and illneonates.53,54 These may includetherapeutic positioning, swaddling,or other strategies. Although thereis controversy regarding theeffectiveness of formalizedprograms for developmentallysensitive care, components of theseapproaches may improve short-term outcomes. Integration ofdevelopmentally sensitive care hasbeen endorsed by professionalorganizations, such as the NationalAssociation of Neonatal Nurses,with development of guidelines andquality metrics.54–64

Therapeutic positioning keeps theinfant contained and maintains thefetal midline position of flexion tosupport comfort and self-regulation.55–59 This positioningmay involve the time-limited useof positioning devices, includingblanket rolls and commerciallyavailable products. Withoutsupport from these devices, thepreterm infant will lie flat andasymmetric with hips and jointsabducted with abnormal rotation.Over time, this may lead tomusculoskeletal andneurodevelopmentalabnormalities, including upperextremity hyperabduction andflexion and generalized muscularrigidity.55 Positioning devices areincompatible with a safe homesleep environment and, althoughthe AAP encourages transitioningto a safe sleep environment at 32weeks’ postmenstrual age, not allinfants will have achievedpositional stability by this age,resulting in wide interpretation atthe bedside.7,65–67 Through qualityimprovement research, somecenters have developed programsfor consistent timing andincreased compliance with safe

sleep recommendations8,11,68–73

(see section on A RationalApproach to Transition of theNICU Patient to a Home SleepEnvironment).

Positional or DeformationalPlagiocephaly

Positional or deformationalplagiocephaly (DP) (mostcommonly unilateral flattening ofthe parieto-occipital region, withcompensatory anterior shift of theipsilateral ear and anteriordisplacement of the ipsilateralforehead) results from unevenlydistributed external pressureresulting in abnormal headshape.74 DP is common in theNICU and may occur secondary tolimitations on positioning, muscletone, nursing care practices, andother medical conditions.75,76

Preterm infants are moresusceptible to developingplagiocephaly attributable todecreased mineralization of theskull bones, increased pronepositioning, placing the infantrepeatedly on the same side andslower motor development.Although pediatric occupationaland physical therapists frequentlyuse a variety of positioning devicesand supports to correct DP (andthe often accompanyingtorticollis),77–80 these productsshould be removed before hospitaldischarge, because they arecontrary to home safe sleeprecommendations. Thus, hometherapy should be limited tocreating a nonrestrictiveenvironment that promotesspontaneous physical movementand symmetrical motordevelopment.81,82

As infants who requiredevelopmentally sensitive care ortreatment of DP mature andapproach discharge readiness, aninterdisciplinary, collaborative, andthoughtful approach is required to

determine how and whenpositioning devices should bediscontinued and removed toachieve a safe home sleepenvironment. In addition,communication with andeducation of the infant’s family arecrucial to promote understandingof safe sleep practices anddecrease the inappropriate use ofthe devices after hospitaldischarge.

SKIN-TO-SKIN CARE AND THE USE OF ASEPARATE SLEEP SURFACE

The benefits of skin-to-skin care(SSC) are numerous and includeimproved initiation andmaintenance of breastfeeding,thermoregulation and glucosehomeostasis, decreased crying, andcardiorespiratory stability.83–87 Inpreterm infants, SSC improvesautonomic and neurobehavioralmaturation and results in bettersleep patterns and growth.58,88

However, there are potentialcomplications, including infant fallsand sudden unexpected postnatalcollapse, when SSC is notappropriately monitored. When SSCis performed in the NICU, closemonitoring is important, and theparent should be educated about thedangers of sharing a sleep surface,whether in the hospital or home.Although parents mayunintentionally fall asleep with theirinfant at home, this is especiallydangerous with the preterm or lowbirth weight infant.3,13,89 Thus, it isimportant to reinforce safe sleepeducation when mothers arerooming-in with their infants andare not under the constantobservation of NICU staff. The riskof falls and sudden unexpectedpostnatal collapse should bemitigated by conducting frequentassessments and monitoring of themother-infant dyad for maternalfatigue. If the caregiver isbecoming drowsy while caring forthe infant, then the infant should

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be moved to a separate sleepsurface.87

THERMOREGULATION

In the NICU, thermoregulation issuestend to focus on the prevention ofhypothermia, because it is wellestablished that achievingnormothermia optimizes outcomes,including reductions in mortality.Preterm infants have more difficultywith thermoregulation than terminfants; however, this improves withmaturation.90 Although weight-based criteria for weaning from theincubator to open bassinet variesamong NICUs, a Cochrane reviewfound that transfer out ofthermoregulatory support at aweight of 1600 g did not adverselyaffect temperature stability orweight gain.91–94

As preterm infants stabilize in anopen environment, attention shouldbe redirected from hypothermia tomodeling safe sleep with theprevention of overheating andoverbundling. Families should beeducated on evaluating the infant forsigns of overheating, such as sweatingor the torso feeling hot to the touch.2

Parents should also be warned aboutthe potential for head covering,including hats, to contribute tooverheating and thermal stress. Arecent article found that in a largecohort of preterm infants, the failurerate attributable to hypothermia fortransitioning out of supplemental heatwithout a hat was 2.7%.95 Given thequestionable benefit of hat use andthe potential for overheating withhead coverings, clinicians shouldcarefully weigh the risks and benefitsregarding the discharge of an infantfrom the NICU with a hat. If the infantis discharged wearing a hat duringsleep, the clinician should provideeducation to the family regardingdiscontinuation once the infantachieves stable temperatures in thehome environment. This shouldinclude education about how to

determine that the infant'stemperature is stable.

SWADDLING

In the NICU, swaddling, or the snugwrapping of an infant in a lightblanket, is an important part ofdevelopmentally sensitive care. Whenswaddled, preterm infants should beplaced in the supine position, havetheir hands brought to midline underthe chin, and hips and knees shouldbe in the flexed position and able tomove freely.96 Swaddling may beuseful in helping preterm infantsmaintain a normal temperature.

Swaddling is also commonly used inthe care of infants with NOWS.Although no studies specificallyaddress swaddling in thispopulation, it has been suggestedthat it is beneficial in decreasingexcessive crying and promotion ofsleep.39,40 This may be related toinhibition of the Moro reflex whenswaddling with the arms tucked inthe swaddle.

When infants are swaddled,wearable blankets (which often havea swaddle wrap component) arepreferred to conventional blanketsfor providing warmth whilepreventing head covering. Properswaddling technique should allowthe hips to be flexed and abductedto reduce the risk of exacerbatingdevelopmental dysplasia of thehip.97

Because there is a much greater riskof sudden unexpected death ifinfants are swaddled and thenplaced in a nonsupine position,97–100

care must be taken to always placeswaddled infants supine. In addition,when the infant begins to attempt toroll over, swaddling should bediscontinued.

HUMAN MILK AND BREASTFEEDING

There are numerous benefits tobreastfeeding, including decreased

risk of infection and decreased riskof allergies, asthma, eczema, obesity,inflammatory bowel disease, highcholesterol, type 1 diabetes mellitus,SIDS, and possibly some childhoodcancers.101–104 In the preterm infant,human milk has also been shown toimprove feeding tolerance andreduce the risk of necrotizingenterocolitis.105–108

Given both the early and long-termbenefits for the preterm infant,clinicians should provide familyeducation on the importance ofhuman milk on admission to theNICU or earlier if possible.109

Multidisciplinary teams should beavailable to support breastfeedingand expression and provision ofmother’s milk, not just during thehospitalization but also afterdischarge for the transition to directbreastfeeding at home.110,111

A RATIONAL APPROACH TO TRANSITIONOF THE NICU PATIENT TO A HOMESLEEP ENVIRONMENT

Programs to model and teach safeinfant sleep in both the newbornnursery and the NICU have beendeveloped.8,11,68–73,112,113 Theseprograms typically includestandardized policies for infantsleep safety consistent with AAPrecommendations, education forboth staff and families, visibleeducational prompts, modeling ofsafe sleep, and audits for qualityimprovement. One NICU studydemonstrated maintenance ofimprovement at 6-month auditsafter intervention, with 98% ofinfants lying supine in open cribs,93% in a wearable blanket, and88% of bassinets with a visiblesafe sleep card.71 Furthermore,standardized programs have beenassociated with higher rates ofsupine sleep and other safe sleepbehaviors in the home.11,72,73

One of the challenges in transitioningthe NICU patient to a safe home

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sleep environment relates toresolving therapeutic positioningpractices for the infant that areinconsistent with sleep safety athome. Although the AAP through itsCommittee on Fetus and Newbornrecommends that “hospitalizedpreterm infants should be keptpredominantly in the supine position,at least from the postmenstrual ageof 32 weeks onward, so that theybecome acclimated to supinesleeping before discharge,”5 not allinfants will be clinically ready to bemaintained in such a sleepenvironment at that age. To manageclinical variability, algorithms havebeen developed on the basis ofliterature review, expert opinion, andunit consensus.11,114 Qualityimprovement programs using thesealgorithms have demonstrated moreconsistent modeling in the NICU andimproved parental adherence withsafe sleep practices after hospitaldischarge.11,114 In one study, 2Massachusetts community NICUsimproved overall adherence withpractices consistent with sleep safetyat home from 25.9% to 79.7% (P <

.001),114 and this standardizedapproach to integrating these safesleep practices into routine NICUcare was adopted by all NICUsstatewide.115 In another study, adecision-guiding algorithm led tosignificant improvement in bothNICU staff and parental compliance,with safe sleep practices in the homeincreasing from 23% to 82% (P <

.001).11

Creating a culture of infant sleepsafety in the NICU setting can bechallenging. Resistance to change iscommon, so consensus-building isessential to success. An algorithmsuch as that published by Gelfer etal11 can be used as a starting point forthe input of a multidisciplinary teamincluding all of those involved withthe care of the infant, including butnot limited to physicians, advancedpractice providers, nursing staff,

lactation consultants, respiratorytherapists, and developmentaltherapists (physical therapy,occupational therapy, speech therapy).

Clinicians must address the acutephysiologic needs of the NICUinfant; incremental transition to asafe home sleep environment canbegin as these needs resolve.Because preterm infants are atincreased risk of SUID, cliniciansshould provide regular, repetitive,and consistent safe sleepeducation with familiesthroughout the hospitalization.Through messaging with not onlywords but also modelingbehaviors, clinicians will enableNICU families to be betterprepared for the transition to asafe home sleep environment.

RECOMMENDATIONS

Overall recommendations fortransition to safe home sleep for theNICU patient are provided below.Table 1 summarizes transition issuesas pertaining to infant sleep safety.

1. The intensive care nurseryshould develop a safe sleep poli-cy incorporating the points be-low, with the goal oftransitioning the infant to a safehome sleep environment consis-tent with the recommendationsof the AAP Task Force onSIDS.8,69,72,112,113,116–120

2. The NICU should use an algo-rithm for routine and repeatedevaluation of each NICU infantfor safe home sleepreadiness.11,114,115

3. Incremental implementation ofcomponents of a safe sleep envi-ronment can be implementedfor NICU infants not ready tocompletely transition to a safehome sleep environment (eg,the infant may be ready for su-pine positioning but may stillneed positioners forplagiocephaly).11,114,115

4. All staff involved in the care ofNICU infants should receive ed-ucation on and maintain exper-tise in infant sleep safety,including the AAP recommenda-tions, hospital policy, and transi-tional algorithm.*

5. Family education regardinginfant sleep safety should beprovided early and oftenthroughout the hospitalcourse.† Multiple communica-tion strategies (bedside cards,whiteboards) should be usedto increase parental aware-ness and provide anticipatoryguidance for NICU infants whoare not clinically ready totransition to a safe homesleep environment. One exam-ple is a bedside card denotingthat the infant is receivingtherapeutic positioning be-cause of prematurity orillness.11,114,115,121

6. When the infant is deemedready for transition to a safehome sleep environment, thetherapeutic positioning cardshould be replaced with messag-ing that the infant is now beingmaintained in a safe sleepenvironment.11,114,115,121

7. When the infant transitions tothe safe home sleep environ-ment, consideration should begiven to using this opportunityto provide formal safe sleep ed-ucation for the family and cele-brate the event on par with adevelopmentalmilestone.11,114,115,121

8. If an infant has a clinical deteri-oration after going into a safehome sleep environment, thentherapeutic positioning mayneed to be reinstituted. As soonas the infant is clinically stableagain, he or she should be

*Refs 8, 11, 69, 72, 73, 112–115, 118, and120–123.†Refs 8, 11, 68–70, 72, 112, 113, 118–120, and122–125.

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TABLE 1 NICU Transition to a Safe Home Sleep Environment

Respiratory distress11,14,16,17,24,66,112,114

a. For the infant with acute respiratory distress, regardless of gestational age, nonsupine positioning may be used as clinically indicated to stabilize/improve respiratory function.

b. If nonsupine positioning is used, especially as the infant matures, parents should be educated about infant home sleep safety and the reasons forusing therapeutic positioning.

c. Once the acute respiratory distress is resolving, the infant should be placed supine for modeling infant home sleep safety, and the parents shouldreceive additional education before hospital discharge.

d. For infants who have developed chronic lung disease, periodic assessments should be performed to monitor the infant’s progress. Once the infanthas weaned to a standardized minimal supplemental respiratory support (determined by the individual institution), then supine positioning can bemaintained, and parents should receive additional education before hospital discharge.

e. The management of the infant with upper airway obstruction needs to be individualized on the basis of the severity of the obstruction. Nonsupinepositioning may be necessary to prevent excessive hypercarbia or hypoxemia and consideration should be given to home monitoring of themarginal airway.

Apnea of prematurity27–29,134

a. There is inadequate evidence to justify the use of prone positioning for the treatment of apnea of prematurity.b. For more information on apnea of prematurity, please refer to the clinical report on apnea of prematurity from the AAP.134

Gastroesophageal reflux and GERD4,30,33

a. Gastroesophageal reflux is extremely common in infants in the NICU.b. Because of the increased risk of SUID, infants with gastroesophageal reflux or GERD should not have the head of the bed elevated, nor should theybe laid down on their side or prone.

c. For more information refer to the clinical report on gastroesophageal reflux in the preterm infant by the AAP.Hyperbilirubinemia and phototherapy36,38,135,136

a. There is no benefit to changing infant position while undergoing phototherapy.b. Unless there are other competing medical issues, infants should be kept supine while receiving phototherapy to model and promote infant homesleep safety.

NOWS2,39–41

a. There are some commonly used therapeutic interventions in the treatment of NOWS (ie, prone positioning) that are not consistent with infant homesleep safety.

b. Early and frequent education is critical to prevent families from thinking that the proper use of therapeutic interventions in the hospital can bereplicated in the home environment.

c. The use of therapeutic interventions that are not consistent with infant home sleep safety should be minimized. When interventions are necessary,it is important to review their use and attempt to transition to a safe home sleep environment as soon as clinically stable.

d. Clear, consistent, safe home sleep messaging should be emphasized repeatedly with families of infants with NOWS throughout the hospitalization.Developmentally sensitive care11,71,112,114,119

a. Developmentally sensitive care is an important component to the health and well-being of the preterm infant.b. Although many of the tools and therapies used to promote developmentally sensitive care are not consistent with a safe home sleep environmentfor infants, parental observation of these techniques can serve as a teachable moment for eventual safe sleep readiness.

c. It is important to transition infants to a safe home sleep environment as early as possible before NICU discharge.d. Good communication with the use of a multidisciplinary team is key for consistent transitioning of NICU patients to a safe infant home sleep

environment (see A Rational Approach to Transition of the NICU Patient to a Home Sleep Environment for details).DP and torticollis2,77–82

a. Positioning devices recommended by qualified personnel, such as but not limited to occupational and physical therapists, can be used to prevent,control, and correct DP and torticollis while infants are under continuous monitoring in the NICU.

b. Parents need to be educated regarding the use of sleep positioning devices: that their use is limited to the inpatient setting under strictmonitoring, and that they are not part of a safe home sleep environment.

c. Education regarding tummy time should emphasize that it be performed during awake, supervised periods only and never when the infant isasleep, even with “close” supervision.

Thermoregulation2,90,94,99,100,137–140

a. Preterm and low birth weight infants are prone to temperature instability and may require additional bundling to avoid hypothermia.b. Excessive bundling needs to be avoided because overheating and head covering have been associated with an increased risk of SUID.c. If an infant is discharged wearing a hat, families should be counseled to discontinue its use once the infant demonstrates temperature stability inthe home environment.

d. If swaddling is performed, it is important that it is done properly, the infant is always placed supine, and it is discontinued before the infant isable to roll over.

DDH97–100

a. Infants are frequently swaddled in the NICU when approaching hospital discharge; however, improper swaddling can lead to or exacerbate DDH.Proper swaddling technique should allow the hips to be flexed and abducted.

b. Parents should be well-educated about all safety issues regarding swaddling, in particular the increased risk of SUID with nonsupine positioning.c. For more information refer to the clinical report on DDH by the AAP.

Human milk and breastfeeding2,87,89,101–104,110,111

a. The use of human milk is recommended for its numerous health benefits, including a reduced risk for SIDS.b. Special care should be taken when mothers are rooming-in and breastfeeding to minimize the risk of falling asleep with the infant in the adultbed.

c. Provide mothers with appropriate outpatient support to optimize breastfeeding success after hospital discharge.

DDH, developmental dysplasia of the hip.

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returned to a safe home sleepenvironment.11,114,115,121

9. Before hospital discharge, allNICU families should receivestandardized safe infant sleep ed-ucation and be queried about asafe home sleep environment fol-lowed by applicable counseling.‡

10. If the family does not have themeans for a safe home sleep envi-ronment, then a referral should bemade to social work for assistanceand/or referral to resources thatcan provide cribs or portable playyards at low or no cost.126–129

11. Crib audits should be an integralcomponent of a NICU safe sleepprogram to monitor success oridentify areas for improvement.Consider the use of run chartsto allow staff to see real-timefeedback on whether an inter-vention is working. This is inte-gral for determining the needfor and implementation of plan-do-study-act cycles.§

12. Consideration should be givento incorporating safe sleep edu-cation into the electronic medi-cal record. Examples includeassessments for a safe sleepinghome environment and alerts toperform the assessment andcomplete the education.130–133

13. Include primary and ancillarycare providers and neurodeve-lopmental teams in preparationfor a smooth transition to homethat includes maintenance and

reinforcement of a safe homesleep environment.

LEAD AUTHORSMichael H. Goodstein, MD, FAAPDan L. Stewart, MD, FAAPErin L. Keels, DNP, APRN, NNP-BCRachel Y. Moon, MD, FAAP

COMMITTEE ON FETUS AND NEWBORN,2019–2020James Cummings, MD, FAAP, ChairpersonIvan Hand, MD, FAAPIra Adams-Chapman, MD, MD, FAAPSusan W. Aucott, MD, FAAPKaren M. Puopolo, MD, FAAPJay P. Goldsmith, MD, FAAPDavid Kaufman, MD, FAAPCamilia Martin, MD, FAAPMeredith Mowitz, MD, FAAP

LIAISONSTimothy Jancelewicz, MD, FAAP – AmericanAcademy of Pediatrics Section on SurgeryMichael Narvey, MD – Canadian PaediatricSocietyRussell Miller, MD – American College ofObstetricians and GynecologistsRADM Wanda Barfield, MD, MPH, FAAP –Centers for Disease Control and PreventionLisa Grisham, APRN, NNP-BC – NationalAssociation of Neonatal Nurses

STAFFJim Couto, MA

TASK FORCE ON SUDDEN INFANTDEATH SYNDROMERachel Y. Moon, MD, FAAP, ChairpersonElie Abu Jawdeh, MD, PhD, FAAPRebecca Carlin, MD, FAAPJeffrey Colvin, MD, JD, FAAP

Michael H. Goodstein, MD, FAAPFern R. Hauck, MD, MS

CONSULTANTSElizabeth Bundock, MD, PhD – NationalAssociation of Medical ExaminersLorena Kaplan, MPH – Eunice KennedyShriver National Institute for Child Healthand Human DevelopmentSharyn Parks Brown, PhD, MPH – Centersfor Disease Control and PreventionMarion Koso-Thomas, MD, MPH – EuniceKennedy Shriver National Institute for ChildHealth and Human DevelopmentCarrie K. Shapiro-Mendoza, PhD, MPH –Centers for Disease Control and Prevention

STAFFJames Couto, MA

ABBREVIATIONS

AAP: American Academy ofPediatrics

DP: deformational plagiocephalyGERD: gastroesophageal reflux

diseaseNICE: National Institute for

Health and ClinicalExcellence

NOWS: neonatal opioidwithdrawal syndrome

SIDS: sudden infant deathsyndrome

SSC: skin-to-skin careSUID: sudden unexpected infant

death

DOI: https://doi.org/10.1542/peds.2021-052045

Address correspondence to Michael Goodstein, MD. Email: mgoodstein@wellspan.org

PEDIATRICS (ISSN Numbers: Print 0031-4005; Online, 1098-4275).

Copyright# 2021 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

‡Refs 8, 69, 72, 112, 113, 119, 120, and 122–125.§Refs 11, 69, 73, 112–115, 118, 119, 121, 122, and 125.

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 2, 2021www.aappublications.org/newsDownloaded from

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