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 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report “Transition to a Safe Home Sleep Environment for the NICU Patient,” included in this issue of Pediatrics.

Sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), is the leading cause of postneonatal mortality in the United States. In up to 95% of these cases, there are one or more environmental risk factors identified.1  Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly,2,3  so it is particularly important to model a safe home sleep environment in the NICU before a neonate is discharged from the hospital. The American Academy of Pediatrics (AAP), through the Committee on Fetus and Newborn, has recommended since 2008 that preterm infants be transitioned to a predominantly supine position by a postmenstrual age of 32 weeks to promote safe sleep, a recommendation supported by the AAP Task Force on Sudden Infant Death Syndrome (henceforth, “task force”).2,4,5  Because the recommendations for infant sleep safety at home also include other postnatal environmental factors (eg, use of a firm, flat sleep surface, avoidance of loose bedding or soft objects, a neutral thermal environment, room sharing without bed sharing, smoke-free environment), safe sleep recommendations for NICU patients should also address these factors. Recognizing that not all infants are ready for such a sleep environment by 32 weeks’ postmenstrual age, the task force recommends transitioning the infant to the safe home sleep practices as soon as he or she is medically stable and significantly before the anticipated discharge from the hospital.4 

Studies have shown that NICU providers do not consistently support infant sleep safety recommendations.57  Researchers in a 2016 study of 96 NICU nurses found that only 53% strongly agreed that safe sleep recommendations make a difference in preventing SIDS, and only 20% strongly agreed that parents would model nurses’ behaviors at home.7  However, research from the well-baby nursery, community settings, and the NICU demonstrate that safe sleep education and modeling in these sites translate into increased knowledge and improved safe sleep practices among new parents.811 

This clinical report reviews the evidence for common NICU sleep practices and provides guidance for transitioning the infant to a sleep environment that is safe and appropriate for the home environment.

Since 1992, back sleeping has been recommended for the reduction of sleep-related deaths. This recommendation, in conjunction with the Back to Sleep campaign in 1994, resulted in SIDS rates in the United States decreasing by 53% by 1999.12  Prone and side sleep positions are associated with an increased risk of SIDS, and neither are recommended.4  The risk of SIDS for preterm and low birth weight infants in the prone position is potentially greater than that of healthy term infants.4,13  However, there are a number of scenarios in the NICU in which nonsupine positioning is applied for potential therapeutic benefit. Nonsupine positioning in the NICU in all cases can be used as a teachable moment with the family regarding eventual readiness for safe infant sleep positioning and environment.

Prone positioning is commonly used in infants with both acute and chronic respiratory distress. Preterm infants in the prone position have improved oxygenation and pulmonary function, including dynamic lung compliance and tidal volume, as well as less intrapulmonary shunting and improved thoraco-abdominal synchrony.1416  In the supine position, some lung tissue is dependent to the heart and mediastinal structures, increasing potential for atelectasis. In addition, in the supine position, abdominal contents may limit ventilation through opposition to the excursion of the diaphragm.14,17  A Cochrane review of positioning for acute respiratory distress in infants and children found small but statistically significant improvements in oxygenation and tachypnea with prone positioning.18  The benefit of prone positioning during the acute phase of respiratory disease (when infants are closely monitored) may outweigh the importance of modeling safe sleep positioning in the extremely preterm infant.

Data are more limited regarding potential benefits of prone positioning in the preterm infant with evolving chronic lung disease. The studies are small and have shown conflicting results.1923  One study found higher oxygen saturations and functional residual capacity in the prone position but no difference in compliance or resistance in oxygen-dependent infants.19  Another study found prone positioning increased tidal volumes and minute ventilation but also increased work of breathing.22  Although undefined, at some point the diminishing benefits of prone positioning are outweighed by the concern of reinforcing a sleep position that increases the risk of SUID.

Although uncommon, there are congenital airway abnormalities that result in respiratory compromise, and some infants with these conditions may benefit from prone positioning. The benefit of prone positioning is particularly relevant in Pierre Robin sequence, in which there is gravity-dependent tongue-based obstruction.24  Although infants with mild cases of Pierre Robin sequence will be stable sleeping supine and infants with severe cases will have early surgical intervention, intermediate cases may be more challenging and achieve relief with prone positioning until they outgrow their airway obstruction.

Some studies have suggested that the frequency and severity of apnea of prematurity may be decreased through prone positioning, but these studies showed mild benefit and were limited by small sample size.25,26  More recent studies have disputed this conclusion.27,28  A 2017 Cochrane review found no statistical differences in apnea, bradycardia, or oxygen saturations and concluded that body position was not relevant to controlling apnea frequency.29  Nonsupine positioning should not be used as a strategy to decrease apnea of prematurity.

Positioning has often been touted as a treatment of gastroesophageal reflux disease (GERD), but the risk of sudden unexpected death has decreased enthusiasm for this strategy. The AAP agrees with the recommendation of both the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition “not to use positional therapy (ie, head elevation, elevation of the head of the crib, lateral and prone positioning) to treat symptoms of GERD in sleeping infants.”30  Studies have suggested less reflux when the infant is in the prone position versus the supine position, so it is acceptable to place an awake infant prone after feeding if the infant is continuously monitored.31,32  Although gastric emptying may be improved by placing the infant in the right lateral position, some studies have demonstrated that when preterm infants are placed in the left lateral position after feeding, there is a decrease in the number of transient relaxations of the lower esophageal sphincter.3235  However, infants should not be placed in an inclined or nonsupine position for sleep as treatment of GERD.

Prone positioning is sometimes used in alternation with supine positioning while infants are being treated with phototherapy for hyperbilirubinemia. However, a systematic review found supine positioning was equally effective to periodically turning infants.36  The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom stated that positioning has no significant influence on the mean change in serum bilirubin concentration or the duration of phototherapy for infants born at term.37  As such, the NICE recommends infants be placed in the supine position while being treated with phototherapy to ensure consistent advice about SIDS risk.37  Since the NICE recommendation, a study of infants born at ≥33 weeks’ gestation compared supine with alternating positioning and found identical rates of decrease in total serum bilirubin concentration at 12 and 24 hours after initiation of phototherapy.38  The consistency of the results in both term and preterm infants confirm that barring another medical condition requiring prone position, hyperbilirubinemia should be treated routinely in the supine position.

The infant with neonatal opioid withdrawal syndrome (NOWS) is generally treated with supportive, nonpharmacologic care designed to minimize stimulation and to support the infant’s self-regulation.39,40  In one study, prone positioning was associated with decreased severity of NOWS scores and reduced caloric intake.41  Although prone positioning may be useful for monitored inpatients during the acute withdrawal phase of NOWS, it should be discontinued when possible and before hospital discharge to decrease SUID risk.

Per AAP recommendations, infants at home should be placed on a flat, firm sleep surface (ie, crib, bassinet, portable crib, or play yard that conforms to the safety standards of the Consumer Product Safety Commission)2,42,43  covered by a fitted sheet with no other bedding. Because soft bedding and loose objects in the sleep environment can obstruct the infant’s airway, increasing the risk of rebreathing, SIDS, and suffocation,4452  these items should not be in the sleep environment. Although bedding and positioners are often used for developmentally sensitive care and for treatment of plagiocephaly, these items should be removed from the sleep environment.

Developmentally sensitive care is an important therapeutic intervention for preterm and other ill infants. However, because such care often may be inconsistent with provisions for a safe infant home sleep environment, staff should use demonstration of these techniques as a teachable moment with the family regarding eventual readiness for safe infant sleep positioning and environment.

Developmentally sensitive care refers to a broad category of interventions designed to minimize the stress of the extrauterine environment and optimize the physical and neurodevelopmental outcomes for preterm and ill neonates.53,54  These may include therapeutic positioning, swaddling, or other strategies. Although there is controversy regarding the effectiveness of formalized programs for developmentally sensitive care, components of these approaches may improve short-term outcomes. Integration of developmentally sensitive care has been endorsed by professional organizations, such as the National Association of Neonatal Nurses, with development of guidelines and quality metrics.5464 

Therapeutic positioning keeps the infant contained and maintains the fetal midline position of flexion to support comfort and self-regulation.5559  This positioning may involve the time-limited use of positioning devices, including blanket rolls and commercially available products. Without support from these devices, the preterm infant will lie flat and asymmetric with hips and joints abducted with abnormal rotation. Over time, this may lead to musculoskeletal and neurodevelopmental abnormalities, including upper extremity hyperabduction and flexion and generalized muscular rigidity.55  Positioning devices are incompatible with a safe home sleep environment and, although the AAP encourages transitioning to a safe sleep environment at 32 weeks’ postmenstrual age, not all infants will have achieved positional stability by this age, resulting in wide interpretation at the bedside.7,6567  Through quality improvement research, some centers have developed programs for consistent timing and increased compliance with safe sleep recommendations8,11,6873  (see section on A Rational Approach to Transition of the NICU Patient to a Home Sleep Environment).

Positional or deformational plagiocephaly (DP) (most commonly unilateral flattening of the parieto-occipital region, with compensatory anterior shift of the ipsilateral ear and anterior displacement of the ipsilateral forehead) results from unevenly distributed external pressure resulting in abnormal head shape.74  DP is common in the NICU and may occur secondary to limitations on positioning, muscle tone, nursing care practices, and other medical conditions.75,76  Preterm infants are more susceptible to developing plagiocephaly attributable to decreased mineralization of the skull bones, increased prone positioning, placing the infant repeatedly on the same side and slower motor development. Although pediatric occupational and physical therapists frequently use a variety of positioning devices and supports to correct DP (and the often accompanying torticollis),7780  these products should be removed before hospital discharge, because they are contrary to home safe sleep recommendations. Thus, home therapy should be limited to creating a nonrestrictive environment that promotes spontaneous physical movement and symmetrical motor development.81,82 

As infants who require developmentally sensitive care or treatment of DP mature and approach discharge readiness, an interdisciplinary, collaborative, and thoughtful approach is required to determine how and when positioning devices should be discontinued and removed to achieve a safe home sleep environment. In addition, communication with and education of the infant’s family are crucial to promote understanding of safe sleep practices and decrease the inappropriate use of the devices after hospital discharge.

The benefits of skin-to-skin care (SSC) are numerous and include improved initiation and maintenance of breastfeeding, thermoregulation and glucose homeostasis, decreased crying, and cardiorespiratory stability.8387  In preterm infants, SSC improves autonomic and neurobehavioral maturation and results in better sleep patterns and growth.58,88  However, there are potential complications, including infant falls and sudden unexpected postnatal collapse, when SSC is not appropriately monitored. When SSC is performed in the NICU, close monitoring is important, and the parent should be educated about the dangers of sharing a sleep surface, whether in the hospital or home. Although parents may unintentionally fall asleep with their infant at home, this is especially dangerous with the preterm or low birth weight infant.3,13,89  Thus, it is important to reinforce safe sleep education when mothers are rooming-in with their infants and are not under the constant observation of NICU staff. The risk of falls and sudden unexpected postnatal collapse should be mitigated by conducting frequent assessments and monitoring of the mother-infant dyad for maternal fatigue. If the caregiver is becoming drowsy while caring for the infant, then the infant should be moved to a separate sleep surface.87 

In the NICU, thermoregulation issues tend to focus on the prevention of hypothermia, because it is well established that achieving normothermia optimizes outcomes, including reductions in mortality. Preterm infants have more difficulty with thermoregulation than term infants; however, this improves with maturation.90  Although weight-based criteria for weaning from the incubator to open bassinet varies among NICUs, a Cochrane review found that transfer out of thermoregulatory support at a weight of 1600 g did not adversely affect temperature stability or weight gain.9194 

As preterm infants stabilize in an open environment, attention should be redirected from hypothermia to modeling safe sleep with the prevention of overheating and overbundling. Families should be educated on evaluating the infant for signs of overheating, such as sweating or the torso feeling hot to the touch.2  Parents should also be warned about the potential for head covering, including hats, to contribute to overheating and thermal stress. A recent article found that in a large cohort of preterm infants, the failure rate attributable to hypothermia for transitioning out of supplemental heat without a hat was 2.7%.95  Given the questionable benefit of hat use and the potential for overheating with head coverings, clinicians should carefully weigh the risks and benefits regarding the discharge of an infant from the NICU with a hat. If the infant is discharged wearing a hat during sleep, the clinician should provide education to the family regarding discontinuation once the infant achieves stable temperatures in the home environment. This should include education about how to determine that the infant's temperature is stable.

In the NICU, swaddling, or the snug wrapping of an infant in a light blanket, is an important part of developmentally sensitive care. When swaddled, preterm infants should be placed in the supine position, have their hands brought to midline under the chin, and hips and knees should be in the flexed position and able to move freely.96  Swaddling may be useful in helping preterm infants maintain a normal temperature.

Swaddling is also commonly used in the care of infants with NOWS. Although no studies specifically address swaddling in this population, it has been suggested that it is beneficial in decreasing excessive crying and promotion of sleep.39,40  This may be related to inhibition of the Moro reflex when swaddling with the arms tucked in the swaddle.

When infants are swaddled, wearable blankets (which often have a swaddle wrap component) are preferred to conventional blankets for providing warmth while preventing head covering. Proper swaddling technique should allow the hips to be flexed and abducted to reduce the risk of exacerbating developmental dysplasia of the hip.97 

Because there is a much greater risk of sudden unexpected death if infants are swaddled and then placed in a nonsupine position,97100  care must be taken to always place swaddled infants supine. In addition, when the infant begins to attempt to roll over, swaddling should be discontinued.

There are numerous benefits to breastfeeding, including decreased risk of infection and decreased risk of allergies, asthma, eczema, obesity, inflammatory bowel disease, high cholesterol, type 1 diabetes mellitus, SIDS, and possibly some childhood cancers.101104  In the preterm infant, human milk has also been shown to improve feeding tolerance and reduce the risk of necrotizing enterocolitis.105108 

Given both the early and long-term benefits for the preterm infant, clinicians should provide family education on the importance of human milk on admission to the NICU or earlier if possible.109  Multidisciplinary teams should be available to support breastfeeding and expression and provision of mother’s milk, not just during the hospitalization but also after discharge for the transition to direct breastfeeding at home.110,111 

Programs to model and teach safe infant sleep in both the newborn nursery and the NICU have been developed.8,11,6873 ,112,113  These programs typically include standardized policies for infant sleep safety consistent with AAP recommendations, education for both staff and families, visible educational prompts, modeling of safe sleep, and audits for quality improvement. One NICU study demonstrated maintenance of improvement at 6-month audits after intervention, with 98% of infants lying supine in open cribs, 93% in a wearable blanket, and 88% of bassinets with a visible safe sleep card.71  Furthermore, standardized programs have been associated with higher rates of supine sleep and other safe sleep behaviors in the home.11,72,73 

One of the challenges in transitioning the NICU patient to a safe home sleep environment relates to resolving therapeutic positioning practices for the infant that are inconsistent with sleep safety at home. Although the AAP through its Committee on Fetus and Newborn recommends that “hospitalized preterm infants should be kept predominantly in the supine position, at least from the postmenstrual age of 32 weeks onward, so that they become acclimated to supine sleeping before discharge,”5  not all infants will be clinically ready to be maintained in such a sleep environment at that age. To manage clinical variability, algorithms have been developed on the basis of literature review, expert opinion, and unit consensus.11,114  Quality improvement programs using these algorithms have demonstrated more consistent modeling in the NICU and improved parental adherence with safe sleep practices after hospital discharge.11,114  In one study, 2 Massachusetts community NICUs improved overall adherence with practices consistent with sleep safety at home from 25.9% to 79.7% (P < .001),114  and this standardized approach to integrating these safe sleep practices into routine NICU care was adopted by all NICUs statewide.115  In another study, a decision-guiding algorithm led to significant improvement in both NICU staff and parental compliance, with safe sleep practices in the home increasing from 23% to 82% (P < .001).11 

Creating a culture of infant sleep safety in the NICU setting can be challenging. Resistance to change is common, so consensus-building is essential to success. An algorithm such as that published by Gelfer et al11  can be used as a starting point for the input of a multidisciplinary team including all of those involved with the care of the infant, including but not limited to physicians, advanced practice providers, nursing staff, lactation consultants, respiratory therapists, and developmental therapists (physical therapy, occupational therapy, speech therapy).

Clinicians must address the acute physiologic needs of the NICU infant; incremental transition to a safe home sleep environment can begin as these needs resolve. Because preterm infants are at increased risk of SUID, clinicians should provide regular, repetitive, and consistent safe sleep education with families throughout the hospitalization. Through messaging with not only words but also modeling behaviors, clinicians will enable NICU families to be better prepared for the transition to a safe home sleep environment.

Overall recommendations for transition to safe home sleep for the NICU patient are provided below. Table 1 summarizes transition issues as pertaining to infant sleep safety.

  1. The intensive care nursery should develop a safe sleep policy incorporating the points below, with the goal of transitioning the infant to a safe home sleep environment consistent with the recommendations of the AAP Task Force on SIDS.8,69,72,112,113,116120 

  2. The NICU should use an algorithm for routine and repeated evaluation of each NICU infant for safe home sleep readiness.11,114,115 

  3. Incremental implementation of components of a safe sleep environment can be implemented for NICU infants not ready to completely transition to a safe home sleep environment (eg, the infant may be ready for supine positioning but may still need positioners for plagiocephaly).11,114,115 

  4. All staff involved in the care of NICU infants should receive education on and maintain expertise in infant sleep safety, including the AAP recommendations, hospital policy, and transitional algorithm.*

  5. Family education regarding infant sleep safety should be provided early and often throughout the hospital course. Multiple communication strategies (bedside cards, whiteboards) should be used to increase parental awareness and provide anticipatory guidance for NICU infants who are not clinically ready to transition to a safe home sleep environment. One example is a bedside card denoting that the infant is receiving therapeutic positioning because of prematurity or illness.11,114,115,121 

  6. When the infant is deemed ready for transition to a safe home sleep environment, the therapeutic positioning card should be replaced with messaging that the infant is now being maintained in a safe sleep environment.11,114,115,121 

  7. When the infant transitions to the safe home sleep environment, consideration should be given to using this opportunity to provide formal safe sleep education for the family and celebrate the event on par with a developmental milestone.11,114,115,121 

  8. If an infant has a clinical deterioration after going into a safe home sleep environment, then therapeutic positioning may need to be reinstituted. As soon as the infant is clinically stable again, he or she should be returned to a safe home sleep environment.11,114,115,121 

  9. Before hospital discharge, all NICU families should receive standardized safe infant sleep education and be queried about a safe home sleep environment followed by applicable counseling.

  10. If the family does not have the means for a safe home sleep environment, then a referral should be made to social work for assistance and/or referral to resources that can provide cribs or portable play yards at low or no cost.126129 

  11. Crib audits should be an integral component of a NICU safe sleep program to monitor success or identify areas for improvement. Consider the use of run charts to allow staff to see real-time feedback on whether an intervention is working. This is integral for determining the need for and implementation of plan-do-study-act cycles.§

  12. Consideration should be given to incorporating safe sleep education into the electronic medical record. Examples include assessments for a safe sleeping home environment and alerts to perform the assessment and complete the education.130133 

  13. Include primary and ancillary care providers and neurodevelopmental teams in preparation for a smooth transition to home that includes maintenance and reinforcement of a safe home sleep environment.

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 for using 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 should receive 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 infant has weaned to a standardized minimal supplemental respiratory support (determined by the individual institution), then supine positioning can be maintained, 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. Nonsupine positioning may be necessary to prevent excessive hypercarbia or hypoxemia and consideration should be given to home monitoring of the marginal airway. 
Apnea of prematurity2729 ,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 they be 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 home sleep safety. 
NOWS2,3941  
 a. There are some commonly used therapeutic interventions in the treatment of NOWS (ie, prone positioning) that are not consistent with infant home sleep safety. 
 b. Early and frequent education is critical to prevent families from thinking that the proper use of therapeutic interventions in the hospital can be replicated 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 environment for 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 torticollis2,7782  
 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 strict monitoring, 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 is asleep, even with “close” supervision. 
Thermoregulation2,90,94,99,100,137140  
 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 in the 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 is able to roll over. 
DDH97100  
 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 breastfeeding2,87,89,101104 ,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 adult bed. 
 c. Provide mothers with appropriate outpatient support to optimize breastfeeding success after hospital discharge. 
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 for using 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 should receive 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 infant has weaned to a standardized minimal supplemental respiratory support (determined by the individual institution), then supine positioning can be maintained, 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. Nonsupine positioning may be necessary to prevent excessive hypercarbia or hypoxemia and consideration should be given to home monitoring of the marginal airway. 
Apnea of prematurity2729 ,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 they be 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 home sleep safety. 
NOWS2,3941  
 a. There are some commonly used therapeutic interventions in the treatment of NOWS (ie, prone positioning) that are not consistent with infant home sleep safety. 
 b. Early and frequent education is critical to prevent families from thinking that the proper use of therapeutic interventions in the hospital can be replicated 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 environment for 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 torticollis2,7782  
 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 strict monitoring, 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 is asleep, even with “close” supervision. 
Thermoregulation2,90,94,99,100,137140  
 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 in the 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 is able to roll over. 
DDH97100  
 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 breastfeeding2,87,89,101104 ,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 adult bed. 
 c. Provide mothers with appropriate outpatient support to optimize breastfeeding success after hospital discharge. 

DDH, developmental dysplasia of the hip.

Michael H. Goodstein, MD, FAAP Dan L. Stewart, MD, FAAP Erin L. Keels, DNP, APRN, NNP-BC Rachel Y. Moon, MD, FAAP

James Cummings, MD, FAAP, Chairperson Ivan Hand, MD, FAAP Ira Adams-Chapman, MD, MD, FAAP Susan W. Aucott, MD, FAAP Karen M. Puopolo, MD, FAAP Jay P. Goldsmith, MD, FAAP David Kaufman, MD, FAAP Camilia Martin, MD, FAAP Meredith Mowitz, MD, FAAP

Timothy Jancelewicz, MD, FAAP – American Academy of Pediatrics Section on Surgery Michael Narvey, MD – Canadian Paediatric Society Russell Miller, MD – American College of Obstetricians and Gynecologists RADM Wanda Barfield, MD, MPH, FAAP – Centers for Disease Control and Prevention Lisa Grisham, APRN, NNP-BC – National Association of Neonatal Nurses

Jim Couto, MA

Rachel Y. Moon, MD, FAAP, Chairperson Elie Abu Jawdeh, MD, PhD, FAAP Rebecca Carlin, MD, FAAP Jeffrey Colvin, MD, JD, FAAP Michael H. Goodstein, MD, FAAP Fern R. Hauck, MD, MS

Elizabeth Bundock, MD, PhD – National Association of Medical Examiners Lorena Kaplan, MPH – Eunice Kennedy Shriver National Institute for Child Health and Human Development Sharyn Parks Brown, PhD, MPH – Centers for Disease Control and Prevention Marion Koso-Thomas, MD, MPH – Eunice Kennedy Shriver National Institute for Child Health and Human Development Carrie K. Shapiro-Mendoza, PhD, MPH – Centers for Disease Control and Prevention

James Couto, MA

*

Refs 8, 11, 69, 72, 73, 112115, 118, and 120123.

Refs 8, 11, 6870, 72, 112, 113, 118120, and 122125.

Drs Goodstein and Stewart conceptualized, conducted the literature search, wrote and revised the manuscript, and considered input from all reviewers and the board of directors; Dr Keels conducted the literature search, wrote and revised the manuscript, and considered input from all reviewers and the board of directors; Dr Moon conceptualized and revised the manuscript and considered input from all reviewers and the board of directors; and all authors approved the final manuscript as submitted and take responsibility for the final publication.

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

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

The guidance in this report does not indicate an exclusive course of 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 Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

     
  • AAP

    American Academy of Pediatrics

  •  
  • DP

    deformational plagiocephaly

  •  
  • GERD

    gastroesophageal reflux disease

  •  
  • NICE

    National Institute for Health and Clinical Excellence

  •  
  • NOWS

    neonatal opioid withdrawal syndrome

  •  
  • SIDS

    sudden infant death syndrome

  •  
  • SSC

    skin-to-skin care

  •  
  • SUID

    sudden unexpected infant death

1
Ostfeld
BM
,
Esposito
L
,
Perl
H
,
Hegyi
T
.
Concurrent risks in sudden infant death syndrome
.
Pediatrics
.
2010
;
125
(
3
):
447
453
2
Moon
RY
;
Task Force on Sudden Infant Death Syndrome
.
SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment
.
Pediatrics
.
2016
;
138
(
5
):
e20162940
3
Malloy
MH
.
Prematurity and sudden infant death syndrome: United States 2005-2007
.
J Perinatol
.
2013
;
33
(
6
):
470
475
4
Moon
RY
;
Task Force on Sudden Infant Death Syndrome
.
SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment
.
Pediatrics
.
2016
;
138
(
5
):
e20162938
5
American Academy of Pediatrics Committee on Fetus and Newborn
.
Hospital discharge of the high-risk neonate
.
Pediatrics
.
2008
;
122
(
5
):
1119
1126
6
Aris
C
,
Stevens
TP
,
Lemura
C
, et al
.
NICU nurses’ knowledge and discharge teaching related to infant sleep position and risk of SIDS
.
Adv Neonatal Care
.
2006
;
6
(
5
):
281
294
7
Barsman
SG
,
Dowling
DA
,
Damato
EG
,
Czeck
P
.
Neonatal nurses’ beliefs, knowledge, and practices in relation to sudden infant death syndrome risk- reduction recommendations
.
Adv Neonatal Care
.
2015
;
15
(
3
):
209
219
8
Srivatsa
B
,
Eden
AN
,
Mir
MA
.
Infant sleep position and SIDS: a hospital-based interventional study
.
J Urban Health
.
1999
;
76
(
3
):
314
321
9
Moon
RY
,
Oden
RP
,
Grady
KC
.
Back to Sleep: an educational intervention with women, infants, and children program clients
.
Pediatrics
.
2004
;
113
(
3
,
pt 1
):
542
547
10
Rasinski
KA
,
Kuby
A
,
Bzdusek
SA
,
Silvestri
JM
,
Weese-Mayer
DE
.
Effect of a sudden infant death syndrome risk reduction education program on risk factor compliance and information sources in primarily black urban communities
.
Pediatrics
.
2003
;
111
(
4
,
pt 1
).
11
Gelfer
P
,
Cameron
R
,
Masters
K
,
Kennedy
KA
.
Integrating “Back to Sleep” recommendations into neonatal ICU practice
.
Pediatrics
.
2013
;
131
(
4
).
12
Centers of Disease Control and Prevention
.
Linked birth/infant death records on CDC WONDER online database
.
Available at: https://wonder.cdc.gov/controller/datarequest/D23. Accessed July 2, 2020
13
Oyen
N
,
Markestad
T
,
Skaerven
R
, et al
.
Combined effects of sleeping position and prenatal risk factors in sudden infant death syndrome: the Nordic Epidemiological SIDS Study
.
Pediatrics
.
1997
;
100
(
4
):
613
621
14
Wagaman
MJ
,
Shutack
JG
,
Moomjian
AS
,
Schwartz
JG
,
Shaffer
TH
,
Fox
WW
.
Improved oxygenation and lung compliance with prone positioning of neonates
.
J Pediatr
.
1979
;
94
(
5
):
787
791
15
Kassim
Z
,
Donaldson
N
,
Khetriwal
B
, et al
.
Sleeping position, oxygen saturation and lung volume in convalescent, prematurely born infants
.
Arch Dis Child Fetal Neonatal Ed
.
2007
;
92
(
5
):
F347
F350
16
Wolfson
MR
,
Greenspan
JS
,
Deoras
KS
,
Allen
JL
,
Shaffer
TH
.
Effect of position on the mechanical interaction between the rib cage and abdomen in preterm infants
.
J Appl Physiol (1985)
.
1992
;
72
(
3
):
1032
1038
17
Albert
RK
,
Hubmayr
RD
.
The prone position eliminates compression of the lungs by the heart
.
Am J Respir Crit Care Med
.
2000
;
161
(
5
):
1660
1665
18
Gillies
D
,
Wells
D
,
Bhandari
AP
.
Positioning for acute respiratory distress in hospitalised infants and children
.
Cochrane Database Syst Rev
.
2012
;(
7
):
CD003645
19
Bhat
RY
,
Leipälä
JA
,
Singh
NR
,
Rafferty
GF
,
Hannam
S
,
Greenough
A
.
Effect of posture on oxygenation, lung volume, and respiratory mechanics in premature infants studied before discharge
.
Pediatrics
.
2003
;
112
(
1
,
pt 1
):
29
32
20
Elder
DE
,
Campbell
AJ
,
Galletly
D
.
Effect of position on oxygen saturation and requirement in convalescent preterm infants
.
Acta Paediatr
.
2011
;
100
(
5
):
661
665
21
Levy
J
,
Habib
RH
,
Liptsen
E
, et al
.
Prone versus supine positioning in the well preterm infant: effects on work of breathing and breathing patterns
.
Pediatr Pulmonol
.
2006
;
41
(
8
):
754
758
22
Hutchison
AA
,
Ross
KR
,
Russell
G
.
The effect of posture on ventilation and lung mechanics in preterm and light-for-date infants
.
Pediatrics
.
1979
;
64
(
4
):
429
432
23
Leipälä
JA
,
Bhat
RY
,
Rafferty
GF
,
Hannam
S
,
Greenough
A
.
Effect of posture on respiratory function and drive in preterm infants prior to discharge
.
Pediatr Pulmonol
.
2003
;
36
(
4
):
295
300
24
Insalaco
LF
,
Scott
AR
.
Peripartum management of neonatal Pierre Robin sequence
.
Clin Perinatol
.
2018
;
45
(
4
):
717
735
25
Kurlak
LO
,
Ruggins
NR
,
Stephenson
TJ
.
Effect of nursing position on incidence, type, and duration of clinically significant apnoea in preterm infants
.
Arch Dis Child Fetal Neonatal Ed
.
1994
;
71
(
1
):
F16
F19
26
Heimler
R
,
Langlois
J
,
Hodel
DJ
,
Nelin
LD
,
Sasidharan
P
.
Effect of positioning on the breathing pattern of preterm infants
.
Arch Dis Child
.
1992
;
67
(
3
):
312
314
27
Bhat
RY
,
Hannam
S
,
Pressler
R
,
Rafferty
GF
,
Peacock
JL
,
Greenough
A
.
Effect of prone and supine position on sleep, apneas, and arousal in preterm infants
.
Pediatrics
.
2006
;
118
(
1
):
101
107
28
Keene
DJ
,
Wimmer
JEJ
 Jr
,
Mathew
OP
.
Does supine positioning increase apnea, bradycardia, and desaturation in preterm infants?
J Perinatol
.
2000
;
20
(
1
):
17
20
29
Ballout
RA
,
Foster
JP
,
Kahale
LA
,
Badr
L
.
Body positioning for spontaneously breathing preterm infants with apnoea
.
Cochrane Database Syst Rev
.
2017
;(
1
):
CD004951
30
Rosen
R
,
Vandenplas
Y
,
Singendonk
M
, et al
.
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition
.
J Pediatr Gastroenterol Nutr
.
2018
;
66
(
3
):
516
554
31
Bhat
RY
,
Rafferty
GF
,
Hannam
S
,
Greenough
A
.
Acid gastroesophageal reflux in convalescent preterm infants: effect of posture and relationship to apnea
.
Pediatr Res
.
2007
;
62
(
5
):
620
623
32
Corvaglia
L
,
Rotatori
R
,
Ferlini
M
,
Aceti
A
,
Ancora
G
,
Faldella
G
.
The effect of body positioning on gastroesophageal reflux in premature infants: evaluation by combined impedance and pH monitoring
.
J Pediatr
.
2007
;
151
(
6
):
591
596
,
596.e1
33
Eichenwald
EC
;
Committee on Fetus And Newborn
.
Diagnosis and management of gastroesophageal reflux in preterm infants
.
Pediatrics
.
2018
;
142
(
1
):
e20181061
34
Omari
TI
,
Rommel
N
,
Staunton
E
, et al
.
Paradoxical impact of body positioning on gastroesophageal reflux and gastric emptying in the premature neonate
.
J Pediatr
.
2004
;
145
(
2
):
194
200
35
van Wijk
MP
,
Benninga
MA
,
Dent
J
, et al
.
Effect of body position changes on postprandial gastroesophageal reflux and gastric emptying in the healthy premature neonate
.
J Pediatr
.
2007
;
151
(
6
):
585
590
,
590.e1
2
36
Lee Wan Fei
S
,
Abdullah
KL
.
Effect of turning vs. supine position under phototherapy on neonates with hyperbilirubinemia: a systematic review
.
J Clin Nurs
.
2015
;
24
(
5–6
):
672
682
37
National Institute for Health and Care Excellence
.
Clinical Guideline 98: Jaundice in Newborn Babies Under 28 Days
.
London, United Kingdom
:
National Institute for Health and Care Excellence
;
2016
38
Donneborg
ML
,
Knudsen
KB
,
Ebbesen
F
.
Effect of infants’ position on serum bilirubin level during conventional phototherapy
.
Acta Paediatr
.
2010
;
99
(
8
):
1131
1134
39
Edwards
L
,
Brown
LF
.
Nonpharmacologic management of neonatal abstinence syndrome: an integrative review
.
Neonatal Netw
.
2016
;
35
(
5
):
305
313
40
Ryan
G
,
Dooley
J
,
Gerber Finn
L
,
Kelly
L
.
Nonpharmacological management of neonatal abstinence syndrome: a review of the literature
.
J Matern Fetal Neonatal Med
.
2018
;
32
(
10
):
1735
1740
41
Maichuk
GT
,
Zahorodny
W
,
Marshall
R
.
Use of positioning to reduce the severity of neonatal narcotic withdrawal syndrome
.
J Perinatol
.
1999
;
19
(
7
):
510
513
42
US Consumer Product Safety Commission
.
CPSC Document #5030, Crib Safety Tips: Use Your Crib Safely
.
Washington, DC
:
US Consumer Product Safety Commission
.
43
Moon
RY
;
Task Force on Sudden Infant Death Syndrome
.
SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment
.
Pediatrics
.
2011
;
128
(
5
).
44
Kemp
JS
,
Nelson
VE
,
Thach
BT
.
Physical properties of bedding that may increase risk of sudden infant death syndrome in prone-sleeping infants
.
Pediatr Res
.
1994
;
36
(
1
,
pt 1
):
7
11
45
Hauck
FR
,
Herman
SM
,
Donovan
M
, et al
.
Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study
.
Pediatrics
.
2003
;
111
(
5
,
pt 2
):
1207
1214
46
Scheers
NJ
,
Dayton
CM
,
Kemp
JS
.
Sudden infant death with external airways covered: case-comparison study of 206 deaths in the United States
.
Arch Pediatr Adolesc Med
.
1998
;
152
(
6
):
540
547
47
Chiodini
BA
,
Thach
BT
.
Impaired ventilation in infants sleeping facedown: potential significance for sudden infant death syndrome
.
J Pediatr
.
1993
;
123
(
5
):
686
692
48
Sakai
J
,
Kanetake
J
,
Takahashi
S
,
Kanawaku
Y
,
Funayama
M
.
Gas dispersal potential of bedding as a cause for sudden infant death
.
Forensic Sci Int
.
2008
;
180
(
2-3
):
93
97
49
Shapiro-Mendoza
CK
,
Camperlengo
L
,
Ludvigsen
R
, et al
.
Classification system for the sudden unexpected infant death case registry and its application
.
Pediatrics
.
2014
;
134
(
1
).
50
Kanetake
J
,
Aoki
Y
,
Funayama
M
.
Evaluation of rebreathing potential on bedding for infant use
.
Pediatr Int
.
2003
;
45
(
3
):
284
289
51
Kemp
JS
,
Thach
BT
.
Quantifying the potential of infant bedding to limit CO2 dispersal and factors affecting rebreathing in bedding
.
J Appl Physiol (1985)
.
1995
;
78
(
2
):
740
745
52
Patel
AL
,
Harris
K
,
Thach
BT
.
Inspired CO(2) and O(2) in sleeping infants rebreathing from bedding: relevance for sudden infant death syndrome
.
J Appl Physiol (1985)
.
2001
;
91
(
6
):
2537
2545
53
Coughlin
M
,
Gibbins
S
,
Hoath
S
.
Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice
.
J Adv Nurs
.
2009
;
65
(
10
):
2239
2248
54
Symington
A
,
Pinelli
J
.
Developmental care for promoting development and preventing morbidity in preterm infants
.
Cochrane Database Syst Rev
.
2006
;(
2
):
CD001814
55
Encyclopedia on Early Childhood Development
.
Individualized developmental care for preterm infants
.
2017
.
56
Johnston
C
,
Campbell-Yeo
M
,
Disher
T
, et al
.
Skin-to-skin care for procedural pain in neonates
.
Cochrane Database Syst Rev
.
2017
;(
2
):
CD008435
57
Conde-Agudelo
A
,
Belizán
JM
,
Diaz-Rossello
J
.
Kangaroo mother care to reduce morbidity and mortality in low birthweight infants
.
Cochrane Database Syst Rev
.
2011
;(
3
):
CD002771
58
Baley
J
;
Committee on Fetus And Newborn
.
Skin-to-skin care for term and preterm infants in the neonatal ICU
.
Pediatrics
.
2015
;
136
(
3
):
596
599
59
Shah
PS
,
Herbozo
C
,
Aliwalas
LL
,
Shah
VS
.
Breastfeeding or breast milk for procedural pain in neonates
.
Cochrane Database Syst Rev
.
2012
;(
12
):
CD004950
60
Laffin
M
.
Position Paper: NICU Developmental Care
.
Lonedell, MO
:
National Perinatal Association
;
2008
61
Kenner
C
,
McGrath
J
, eds.
Developmental Care of Newborns and Infants
. 2nd ed.
Chicago, IL
:
National Association of Neonatal Nurses
;
2015
62
Altimier
L
,
Kenner
C
,
Damus
K
.
The Wee Care Neuroprotective NICU Program (Wee Care): the effect of a comprehensive developmental care training program on seven neuroprotective core measures for family-centered developmental care of premature neonates
.
Newborn Infant Nurs Rev
.
2015
;
15
(
1
):
6
16
63
Milette
I
,
Martel
MJ
,
Ribeiro da Silva
M
,
Coughlin McNeil
M
.
Guidelines for the institutional implementation of developmental neuroprotective care in the neonatal intensive care unit. Part A: background and rationale. A joint position statement from the CANN, CAPWHN, NANN, and COINN
.
Can J Nurs Res
.
2017
;
49
(
2
):
46
62
64
National Association of Neonatal Nurses
.
Age-Appropriate Care of the Premature and Critically Ill Hospitalized Infant: Guideline for Practice
.
Glenview, IL
:
National Association of Neonatal Nurses
;
2011
65
Patton
C
,
Stiltner
D
,
Wright
KB
,
Kautz
DD
.
Do nurses provide a safe sleep environment for infants in the hospital setting? An integrative review
.
Adv Neonatal Care
.
2015
;
15
(
1
):
8
22
66
McMullen
SL
.
Transitioning premature infants supine: state of the science
.
MCN Am J Matern Child Nurs
.
2013
;
38
(
1
):
8
12
;
quiz 13–14
67
Grazel
R
,
Phalen
AG
,
Polomano
RC
.
Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: An evaluation of nursing knowledge and practice
.
Adv Neonatal Care
.
2010
;
10
(
6
):
332
342
68
Stastny
PF
,
Ichinose
TY
,
Thayer
SD
,
Olson
RJ
,
Keens
TG
.
Infant sleep positioning by nursery staff and mothers in newborn hospital nurseries
.
Nurs Res
.
2004
;
53
(
2
):
122
129
69
Mason
B
,
Ahlers-Schmidt
CR
,
Schunn
C
.
Improving safe sleep environments for well newborns in the hospital setting
.
Clin Pediatr (Phila)
.
2013
;
52
(
10
):
969
975
70
Colson
ER
,
Bergman
DM
,
Shapiro
E
,
Leventhal
JH
.
Position for newborn sleep: associations with parents’ perceptions of their nursery experience
.
Birth
.
2001
;
28
(
4
):
249
253
71
McMullen
SL
,
Lipke
B
,
LeMura
C
.
Sudden infant death syndrome prevention: a model program for NICUs
.
Neonatal Netw
.
2009
;
28
(
1
):
7
12
72
Goodstein
MH
,
Bell
T
,
Krugman
SD
.
Improving infant sleep safety through a comprehensive hospital-based program
.
Clin Pediatr (Phila)
.
2015
;
54
(
3
):
212
221
73
Kellams
A
,
Parker
MG
,
Geller
NL
, et al
.
TodaysBaby quality improvement: safe sleep teaching and role modeling in 8 US maternity units
.
Pediatrics
.
2017
;
140
(
5
):
e20171816
74
Rogers
GF
.
Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part I: terminology, diagnosis, and etiopathogenesis
.
J Craniofac Surg
.
2011
;
22
(
1
):
9
16
75
Graham
JM
 Jr
,
Kreutzman
J
,
Earl
D
,
Halberg
A
,
Samayoa
C
,
Guo
X
.
Deformational brachycephaly in supine-sleeping infants
.
J Pediatr
.
2005
;
146
(
2
):
253
257
76
Hummel
P
,
Fortado
D
.
Impacting infant head shapes
.
Adv Neonatal Care
.
2005
;
5
(
6
):
329
340
77
Madlinger-Lewis
L
,
Reynolds
L
,
Zarem
C
,
Crapnell
T
,
Inder
T
,
Pineda
R
.
The effects of alternative positioning on preterm infants in the neonatal intensive care unit: a randomized clinical trial
.
Res Dev Disabil
.
2014
;
35
(
2
):
490
497
78
Drake
E
.
Positioning the Neonate for Best Outcomes Monograph
.
Glenview, IL
:
National Association of Neonatal Nurses
;
2017
79
Lockridge
T
,
Podruchny
A
,
Thorngate
I
.
Developmental Care CNE Learning Module Series: Infant Sleep Protocols
.
Glenview, IL
:
National Association of Neonatal Nurses
;
2018
80
Hunter
J
.
Developmental Care CNE Learning Module Series: Therapeutic Positioning: Neuromotor, Physiologic, and Sleep Implications
.
Glenview, IL
:
National Association of Neonatal Nurses
;
2018
81
Aarnivala
H
,
Vuollo
V
,
Harila
V
,
Heikkinen
T
,
Pirttiniemi
P
,
Valkama
AM
.
Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial
.
Eur J Pediatr
.
2015
;
174
(
9
):
1197
1208
82
Klimo
P
 Jr
,
Lingo
PR
,
Baird
LC
, et al
.
Congress of Neurological Surgeons systematic review and evidence-based guideline on the management of patients with positional plagiocephaly: the role of repositioning
.
Neurosurgery
.
2016
;
79
(
5
):
E627
E629
83
Moore
ER
,
Anderson
GC
,
Bergman
N
,
Dowswell
T
.
Early skin-to-skin contact for mothers and their healthy newborn infants
.
Cochrane Database Syst Rev
.
2012
;(
5
):
CD003519
84
Feldman
R
,
Weller
A
,
Sirota
L
,
Eidelman
AI
.
Skin-to-skin contact (Kangaroo care) promotes self-regulation in premature infants: sleep-wake cyclicity, arousal modulation, and sustained exploration
.
Dev Psychol
.
2002
;
38
(
2
):
194
207
85
Feldman
R
,
Eidelman
AI
.
Skin-to-skin contact (Kangaroo Care) accelerates autonomic and neurobehavioural maturation in preterm infants
.
Dev Med Child Neurol
.
2003
;
45
(
4
):
274
281
86
Chwo
MJ
,
Anderson
GC
,
Good
M
,
Dowling
DA
,
Shiau
SH
,
Chu
DM
.
A randomized controlled trial of early kangaroo care for preterm infants: effects on temperature, weight, behavior, and acuity
.
J Nurs Res
.
2002
;
10
(
2
):
129
142
87
Feldman-Winter
L
,
Goldsmith
JP
;
Committee On Fetus and Newborn
;
Task Force On Sudden Infant Death Syndrome
.
Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns
.
Pediatrics
.
2016
;
138
(
3
):
e20161889
88
Cleveland
L
,
Hill
CM
,
Pulse
WS
,
DiCioccio
HC
,
Field
T
,
White-Traut
R
.
Systematic review of skin-to-skin care for full-term, healthy newborns
.
J Obstet Gynecol Neonatal Nurs
.
2017
;
46
(
6
):
857
869
89
Blair
PS
,
Platt
MW
,
Smith
IJ
,
Fleming
PJ
;
CESDI SUDI Research Group
.
Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention
.
Arch Dis Child
.
2006
;
91
(
2
):
101
106
90
Jefferies
AL
;
Canadian Paediatric Society, Fetus and Newborn Committee
.
Going home: Facilitating discharge of the preterm infant
.
Paediatr Child Health
.
2014
;
19
(
1
):
31
42
91
Schneiderman
R
,
Kirkby
S
,
Turenne
W
,
Greenspan
J
.
Incubator weaning in preterm infants and associated practice variation
.
J Perinatol
.
2009
;
29
(
8
):
570
574
92
Shankaran
S
,
Bell
EF
,
Laptook
AR
, et al;
Eunice Kennedy Shriver National Institute of Child Health, and Human Development Neonatal Research Network
.
Weaning of moderately preterm infants from the incubator to the crib: a randomized clinical trial
.
J Pediatr
.
2019
;
204
:
96
102.e4
93
New
K
,
Flenady
V
,
Davies
MW
.
Transfer of preterm infants from incubator to open cot at lower versus higher body weight
.
Cochrane Database Syst Rev
.
2011
;(
9
):
CD004214
94
Fulmer
M
,
Zachritz
W
,
Posencheg
MA
.
Intensive care neonates and evidence to support the elimination of hats for safe sleep
.
Adv Neonatal Care
.
2020
;
20
(
3
):
229
232
95
Barone
G
,
Corsello
M
,
Papacci
P
,
Priolo
F
,
Romagnoli
C
,
Zecca
E
.
Feasibility of transferring intensive cared preterm infants from incubator to open crib at 1600 grams
.
Ital J Pediatr
.
2014
;
40
:
41
96
van Sleuwen
BE
,
L’hoir
MP
,
Engelberts
AC
, et al
.
Comparison of behavior modification with and without swaddling as interventions for excessive crying
.
J Pediatr
.
2006
;
149
(
4
):
512
517
97
van Sleuwen
BE
,
Engelberts
AC
,
Boere-Boonekamp
MM
,
Kuis
W
,
Schulpen
TW
,
L’Hoir
MP
.
Swaddling: a systematic review
.
Pediatrics
.
2007
;
120
(
4
).
98
Ponsonby
AL
,
Dwyer
T
,
Gibbons
LE
,
Cochrane
JA
,
Wang
YG
.
Factors potentiating the risk of sudden infant death syndrome associated with the prone position
.
N Engl J Med
.
1993
;
329
(
6
):
377
382
99
Pease
AS
,
Fleming
PJ
,
Hauck
FR
, et al
.
Swaddling and the risk of sudden infant death syndrome: a meta-analysis
.
Pediatrics
.
2016
;
137
(
6
):
e20153275
100
McDonnell
E
,
Moon
RY
.
Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling
.
J Pediatr
.
2014
;
164
(
5
):
1152
1156
101
Section on Breastfeeding
.
Breastfeeding and the use of human milk
.
Pediatrics
.
2012
;
129
(
3
).
102
Ip
S
,
Chung
M
,
Raman
G
,
Trikalinos
TA
,
Lau
J
.
A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries
.
Breastfeed Med
.
2009
;
4
(
suppl 1
):
S17
S30
103
Hauck
FR
,
Thompson
JM
,
Tanabe
KO
,
Moon
RY
,
Vennemann
MM
.
Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis
.
Pediatrics
.
2011
;
128
(
1
):
103
110
104
Vennemann
MM
,
Bajanowski
T
,
Brinkmann
B
, et al;
GeSID Study Group
.
Does breastfeeding reduce the risk of sudden infant death syndrome?
Pediatrics
.
2009
;
123
(
3
).
105
Herrmann
K
,
Carroll
K
.
An exclusively human milk diet reduces necrotizing enterocolitis
.
Breastfeed Med
.
2014
;
9
(
4
):
184
190
106
Assad
M
,
Elliott
MJ
,
Abraham
JH
.
Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet
.
J Perinatol
.
2016
;
36
(
3
):
216
220
107
Maffei
D
,
Schanler
RJ
.
Human milk is the feeding strategy to prevent necrotizing enterocolitis!
Semin Perinatol
.
2017
;
41
(
1
):
36
40
108
Boyd
CA
,
Quigley
MA
,
Brocklehurst
P
.
Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis
.
Arch Dis Child Fetal Neonatal Ed
.
2007
;
92
(
3
):
F169
F175
109
Briere
CE
,
Lucas
R
,
McGrath
JM
,
Lussier
M
,
Brownell
E
.
Establishing breastfeeding with the late preterm infant in the NICU
.
J Obstet Gynecol Neonatal Nurs
.
2015
;
44
(
1
):
102
113
110
Hallowell
SG
,
Spatz
DL
,
Hanlon
AL
,
Rogowski
JA
,
Lake
ET
.
Characteristics of the NICU work environment associated with breastfeeding support
.
Adv Neonatal Care
.
2014
;
14
(
4
):
290
300
111
Noble
LM
,
Okogbule-Wonodi
AC
,
Young
MA
.
ABM clinical protocol #12: transitioning the breastfeeding preterm infant from the neonatal intensive care unit to home, revised 2018
.
Breastfeed Med
.
2018
;
13
(
4
):
230
236
112
Voos
KC
,
Terreros
A
,
Larimore
P
,
Leick-Rude
MK
,
Park
N
.
Implementing safe sleep practices in a neonatal intensive care unit
.
J Matern Fetal Neonatal Med
.
2014
;
28
(
14
):
1637
1640
113
Kuhlmann
S
,
Ahlers-Schmidt
CR
,
Lukasiewicz
G
,
Truong
TM
.
Interventions to improve safe sleep among hospitalized infants at eight children’s hospitals
.
Hosp Pediatr
.
2016
;
6
(
2
):
88
94
114
Hwang
SS
,
O’Sullivan
A
,
Fitzgerald
E
,
Melvin
P
,
Gorman
T
,
Fiascone
JM
.
Implementation of safe sleep practices in the neonatal intensive care unit
.
J Perinatol
.
2015
;
35
(
10
):
862
866
115
Hwang
SS
,
Melvin
P
,
Diop
H
,
Settle
M
,
Mourad
J
,
Gupta
M
.
Implementation of safe sleep practices in Massachusetts NICUs: a state-wide QI collaborative
.
J Perinatol
.
2018
;
38
(
5
):
593
599
116
McMullen
SL
,
Carey
MG
.
Predicting transition to the supine sleep position in preterm infants
.
ANS Adv Nurs Sci
.
2014
;
37
(
4
):
350
356
117
McMullen
SL
,
Wu
YW
,
Austin-Ketch
T
,
Carey
MG
.
Transitioning the premature infant from nonsupine to supine position prior to hospital discharge
.
Neonatal Netw
.
2014
;
33
(
4
):
194
198
118
Shaefer
SJ
,
Herman
SE
,
Frank
SJ
,
Adkins
M
,
Terhaar
M
.
Translating infant safe sleep evidence into nursing practice
.
J Obstet Gynecol Neonatal Nurs
.
2010
;
39
(
6
):
618
626
119
Zachritz
W
,
Fulmer
M
,
Chaney
N
.
An evidence-based infant safe sleep program to reduce sudden unexplained infant deaths
.
Am J Nurs
.
2016
;
116
(
11
):
48
55
120
Naugler
MR
,
DiCarlo
K
.
Barriers to and interventions that increase nurses’ and parents’ compliance with safe sleep recommendations for preterm infants
.
Nurs Womens Health
.
2018
;
22
(
1
):
24
39
121
Carrier
CT
.
Back to Sleep: a culture change to improve practice
.
Newborn Infant Nurs Rev
.
2009
;
9
(
3
):
163
168
122
McMullen
SL
,
Fioravanti
ID
,
Brown
K
,
Carey
MG
.
Safe sleep for hospitalized infants
.
MCN Am J Matern Child Nurs
.
2016
;
41
(
1
):
43
50
123
Colson
ER
,
Joslin
SC
.
Changing nursery practice gets inner-city infants in the supine position for sleep
.
Arch Pediatr Adolesc Med
.
2002
;
156
(
7
):
717
720
124
Dowling
DA
,
Barsman
SG
,
Forsythe
P
,
Damato
EG
.
Caring about Preemies’ Safe Sleep (CaPSS): an educational program to improve adherence to safe sleep recommendations by mothers of preterm infants
.
J Perinat Neonatal Nurs
.
2018
;
32
(
4
):
366
372
125
Lipke
B
,
Gilbert
G
,
Shimer
H
, et al
.
Newborn safety bundle to prevent falls and promote safe sleep
.
MCN Am J Matern Child Nurs
.
2018
;
43
(
1
):
32
37
126
Carlins
EM
,
Collins
KS
.
Cribs for Kids: risk and reduction of sudden infant death syndrome and accidental suffocation
.
Health Soc Work
.
2007
;
32
(
3
):
225
229
127
Hauck
FR
,
Tanabe
KO
,
McMurry
T
,
Moon
RY
.
Evaluation of bedtime basics for babies: a national crib distribution program to reduce the risk of sleep-related sudden infant deaths
.
J Community Health
.
2015
;
40
(
3
):
457
463
128
Engel
M
,
Ahlers-Schmidt
CR
,
Suter
B
.
Safe sleep knowledge and use of provided cribs in a crib delivery program
.
Kans J Med
.
2017
;
10
(
3
):
1
8
129
Salm Ward
TC
,
McClellan
MM
,
Miller
TJ
,
Brown
S
.
Evaluation of a crib distribution and safe sleep educational program to reduce risk of sleep-related infant death
.
J Community Health
.
2018
;
43
(
5
):
848
855
130
Adams
WG
,
Mann
AM
,
Bauchner
H
.
Use of an electronic medical record improves the quality of urban pediatric primary care
.
Pediatrics
.
2003
;
111
(
3
):
626
632
131
Gioia
PC
.
Quality improvement in pediatric well care with an electronic record
.
Proc AMIA Symp
.
2001
:
209
213
132
Miller
AR
,
Tucker
CE
.
Can health care information technology save babies?
J Polit Econ
.
2011
;
119
(
2
):
289
324
133
Biddle
TL
,
Rust
CL
.
A comprehensive safe-sleep initiative to save babies in Kentucky
.
J Obstet Gynecol Neonatal Nurs
.
2018
;
47
(
3
,
suppl
):
S34
S35
134
Eichenwald
EC
;
Committee on Fetus and Newborn, American Academy of Pediatrics
.
Apnea of prematurity
.
Pediatrics
.
2016
;
137
(
1
):
e20153757
135
Bhethanabhotla
S
,
Thukral
A
,
Sankar
MJ
,
Agarwal
R
,
Paul
VK
,
Deorari
AK
.
Effect of position of infant during phototherapy in management of hyperbilirubinemia in late preterm and term neonates: a randomized controlled trial
.
J Perinatol
.
2013
;
33
(
10
):
795
799
136
National Institute for Health and Care Excellence
.
Clinical Guideline 98: Jaundice in Newborn Babies Under 28 Days
.
London, United Kingdom
:
National Institute for Health and Care Excellence
;
2016
137
Ponsonby
AL
,
Dwyer
T
,
Gibbons
LE
,
Cochrane
JA
,
Jones
ME
,
McCall
MJ
.
Thermal environment and sudden infant death syndrome: case-control study
.
BMJ
.
1992
;
304
(
6822
):
277
282
138
Iyasu
S
,
Randall
LL
,
Welty
TK
, et al
.
Risk factors for sudden infant death syndrome among northern plains Indians
.
JAMA
.
2002
;
288
(
21
):
2717
2723
139
Blair
PS
,
Mitchell
EA
,
Heckstall-Smith
EM
,
Fleming
PJ
.
Head covering - a major modifiable risk factor for sudden infant death syndrome: a systematic review
.
Arch Dis Child
.
2008
;
93
(
9
):
778
783
140
Wilson
CA
,
Taylor
BJ
,
Laing
RM
,
Williams
SM
,
Mitchell
EA
.
Clothing and bedding and its relevance to sudden infant death syndrome: further results from the New Zealand Cot Death Study
.
J Paediatr Child Health
.
1994
;
30
(
6
):
506
512

Competing Interests

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

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