Transition to a Safe Home Sleep Environment for the NICU ......2021/06/21 · a safe sleep...

TECHNICAL REPORT

Transition to a Safe Home SleepEnvironment for the NICU PatientMichael H Goodstein MD FAAPab Dan L Stewart MD FAAPc Erin L Keels DNP APRN-CNP NNP-BCde

Rachel Y Moon MD FAAPf COMMITTEE ON FETUS AND NEWBORN TASK FORCE ON SUDDEN INFANT DEATH SYNDROME

Of the nearly 38 million infants born in the United States in 2018 83had low birth weight (lt2500 g [55 lb]) and 10 were born preterm(gestational age of lt37 completed weeks) Many of these infants andothers with congenital anomalies perinatally acquired infections andother disease require admission to a NICU In the past decadeadmission rates to NICUs have been increasing it is estimated thatbetween 10 and 15 of infants will spend time in a NICUrepresenting approximately 500 000 neonates annually Approximately3600 infants die annually in the United States from sleep-relateddeaths including sudden infant death syndrome InternationalClassification of Diseases 10th Revision (R95) ill-defined deaths (R99)and accidental suffocation and strangulation in bed (W75) Preterm andlow birth weight infants are particularly vulnerable with an incidenceof death 2 to 3 times greater than healthy term infants Thus it isimportant for health care professionals to prepare families to maintaintheir infant in a safe sleep environment as per the recommendations ofthe American Academy of Pediatrics However infants in the NICU settingcommonly require care that is inconsistent with infant sleep safetyrecommendations The conflicting needs of the NICU infant with thenecessity to provide a safe sleep environment before hospital dischargecan create confusion for providers and distress for families This technicalreport is intended to assist in the establishment of appropriate NICUprotocols to achieve a consistent approach to transitioning NICU infantsto a safe sleep environment as soon as medically possible well beforehospital discharge

INTRODUCTION

According to the 2016 policy statement from the American Academy ofPediatrics (AAP) Task Force on Sudden Infant Death Syndrome allinfants including preterm and low birth weight infants in the NICUshould be placed in the supine position for sleep as soon as they are

abstractaDivision of Newborn Services WellSpan Health York PennsylvaniabDepartment of Pediatrics College of Medicine The Pennsylvania StateUniversity Hershey Pennsylvania cDepartment of Pediatrics NortonChildrenrsquos and School of Medicine University of Louisville LouisvilleKentucky dNational Association of Neonatal Nurse PractitionersNational Association of Neonatal Nurses Chicago Illinois eNeonatalAdvanced Practice Nationwide Childrenrsquos Hospital Columbus Ohio andfDivision of General Pediatrics School of Medicine University ofVirginia Charlottesville Virginia

Drs Goodstein and Stewart and Ms Keels conceptualized andconducted the literature search wrote and revised themanuscript and considered input from all reviewers and theboard of directors Dr Moon conceptualized and revised themanuscript and considered input from all reviewers and theboard of directors and all authors approved the final manuscriptas submitted

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics Any conflicts have been resolved througha process approved by the Board of Directors The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content of thispublication

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers However technical 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 Variationstaking into account individual circumstances may be appropriate

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmedrevised or retired at or before that time

To cite Goodstein M H Stewart D L Keels E L et al AAPCOMMITTEE ON FETUS AND NEWBORN TASK FORCE ON SUDDENINFANT DEATH SYNDROME Transition to a Safe Home SleepEnvironment for the NICU Patient Pediatrics2021148(1)e2021052046

PEDIATRICS Volume 148 number 1 July 2021e2021052046 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 2 2021wwwaappublicationsorgnewsDownloaded from

medically stable and significantlybefore their anticipated dischargefrom the hospital In particular verypreterm infants should be keptpredominantly in the supineposition by 32 weeksrsquo postmenstrualage (PMA) so that they becomeacclimated to supine sleeping beforedischarge from the hospital1ndash3

There are many other factors thatdefine a safe sleep environment tominimize the risk of sudden infantdeath syndrome (SIDS) accidentalsuffocation and strangulation andundetermined sleep deaths(collectively known as suddenunexpected infant death [SUID]) asoutlined in the same 2016 policystatement

During NICU hospitalization infantsare routinely kept in anenvironment that is not consistentwith these recommendations fornumerous reasons on the basis ofboth treatment of underlyingpathophysiology as well as thenormal physiology of the preterminfant Pathologic conditionsresulting in short-term respiratorydistress (respiratory distresssyndrome and transient tachypneaof the newborn) or long-termrespiratory compromise(bronchopulmonary dysplasia andpulmonary hypoplasia) result in useof positioning inconsistent with safesleep messaging Other conditionsthat may be pathologic such asgastroesophageal reflux (GER) leadto the use of therapeuticinterventions such as side-lyingposition and elevation of the head ofthe bed maneuvers the literaturesuggests may be of questionablevalue4 To reduce the need fornarcotic and anxiolytic medicationswhich have been reported to haveadverse effects onneurodevelopment5ndash7 infants withneonatal opioid withdrawalsyndrome (NOWS) may bepositioned prone or swaddledfirmly Developmental care for the

optimal growth and maturation ofthe preterm infant can include theuse of nonsupine positioning softmattresses and positionersAlthough developmental care hasbeen shown to be beneficial to thelong-term neurodevelopmentaloutcomes of preterm infants manyof the tools involved in theconstantly monitored NICUenvironment are contraindicatedafter hospital discharge Transitionto a safe sleep environment as soonas medically possible well beforedischarge from the hospital isextremely important because inpreterm infants the adjusted oddsratio (aOR) for SIDS is 185 to 272and for suffocation is 186 to 259compared with term infants and thesleep environment greatly affectsthe risk of these sleep-relateddeaths18

Although the AAP through itsCommittee on Fetus and Newbornrecommended the transition to theuse of the supine position by 32weeksrsquo PMA3 in 2008 and thisrecommendation was supported bythe AAP Task Force on SuddenInfant Death Syndrome in 201112

there is long-term and ongoingnonadherence to thisrecommendation from NICUproviders3910 Research onresistance to this recommendationhas thus far been focused on onlyNICU nurses In a 2006 survey of252 NICU nurses 65 identifiedprone positioning as the bestgeneral sleep position for preterminfants followed by 12 whobelieved either prone or side-lyingposition was the best sleepposition9 In addition the nursessurveyed were inconsistentregarding how they determinedwhen a preterm infant is ready tosleep supine Answers includedclose to discharge (13) whenmaintaining their body temperaturein an open crib (25) PMA of 34 to36 weeks (15) PMA $37 weeks

(13) and when the infantrsquosrespiratory status was stable (6)Nursing beliefs and knowledgecontinue to be a barrier to a cultureof consistent safe sleep messaging A2016 survey of 96 NICU nursesfound that 53 strongly agreed thatrecommendations make a differencein preventing SIDS and only 20strongly agreed that parents wouldmodel nursesrsquo behaviors at home10

Various reasons are given to explainwhy nonsupine positioning andother common practices contrary toa safe sleep environment persisteven when infants are approachingdischarge from the NICU Howeverstudies find that when expectant ornew parents receive education oninfant sleep safety on a consistentbasis their knowledge increases andtheir safe sleep behaviors improveregardless of the setting (eg well-infant nursery NICU SpecialSupplemental Nutrition Program forWomen Infants and Children officecommunity health center)11ndash14 Thepurpose of this report is to addressthe many issues that result inconflict with safe sleep guidelineslooking at the validity of practicesbased on review of the evidenceregarding pathophysiology andnormal physiology of the vulnerableinfant The goal of this technicalreport is not to provide an all-encompassing review of theliterature for each issue but rather asummary of data for each issue andprovide suggestions to resolveconflicting practices By creating aconsistent approach to transitioningthe infant in the NICU to a safe sleepenvironment as soon as medicallypossible well before hospitaldischarge families can be exposedto modeling of safe sleep behaviorsthat could decrease the risk of SUIDin this vulnerable population Areasof concern include developmentalcare andor neurodevelopmentalissues positional plagiocephaly andor torticollis orthopedic issues

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 2 2021wwwaappublicationsorgnewsDownloaded from

(developmental hip dysplasia)respiratory distress GER andoraspiration thermoregulationjaundice and neonatal drugwithdrawal Some of this contentand the advice provided may also beapplicable to infants in the wellnewborn and pediatric inpatientunits

DEVELOPMENTALLY SENSITIVE CARE

Infants born preterm have increasedrisks of poor neurodevelopmentaloutcomes with risks increasing asthe gestational age decreases1516

Developmentally sensitive care is abroad term given to a number ofinterventions aimed at modifyingthe imperfect extrauterineenvironment to optimize physicaland neurodevelopmental outcomesfor preterm and ill neonates17 Thisis achieved through a patient-centered approach that protectssleep manages pain and stresssupports essential activities of dailyliving (ie positioning feeding andskin care) integrates family andorcaregivers into the plans of careand modifies the physicalenvironment17 Conflictinginformation exists about theeffectiveness of formalized andprogrammatic approaches todevelopmentally sensitive care1819

However there is evidence thatcomponents of these approachesparticularly skin-to-skin care(SSC)20ndash22 and breastfeeding23

promote improved short-termoutcomes in response to thesuboptimal environment of theNICU Despite the disagreements inthe literature about the effects ofprograms or packages ofdevelopmental care integration ofdevelopmentally sensitive care inthe NICU has been endorsed byprofessional organizations2425 andformal programs recommendationsguidelines and quality metricsexist26ndash28 Commonly usedtechniques of developmental carethat may affect the appropriate

transition to safe sleep includepositioning use of positioning aidsswaddling and SSC

Positioning and Use of PositioningAids

As the fetus rapidly grows in sizeduring the third trimester ofpregnancy the intrauterineenvironment becomes morerestrictive and the fetus moves intoa midline position of flexion29 Thisposition of the head shoulder hipand knee flexion scapularprotraction and posterior pelvic tilthelp the fetus develop appropriateskeletal shapes flexor muscle tonestretch reflexes and self-regulatingbehaviors29 With preterm birthcomes among other things loss ofthe physiologic flexion positioning ofthe intrauterine environment29 Ifnot supported the preterm infantlies flat and asymmetric with hipand joints abducted with abnormalrotation unable to bring himself orherself to a flexed and midlineposition for comfort and self-regulation Over time this may leadto musculoskeletal andneurodevelopmental abnormalitiessuch as upper extremityhyperabduction and flexion andgeneralized muscular rigidity Tohelp prevent these morbidities andprovide comfort and decreasemeasures of stress neonatal nursesfamilies and other caregiverstherapeutically position the preterminfant in a flexed midline andcontained position with the headand neck in a neutral postureshoulders rounded with handsbrought to the midline trunk in ldquoCrdquocurve pelvis in posterior tilt hipsand legs in symmetrical and neutralflexion and rotation and feetsupported29ndash31 Therapeuticpositioning is achieved through theuse of various positioning devicesand supports such as diapers orblanket rolls as well as commerciallyavailable products30ndash33 Currentlythere is no standardized protocol or

device to direct and providetherapeutic positioning leaving thechoice in many cases to theindividual nurse or caregiver34 TheInfant Positioning Assessment Toolwas developed to help providecaregiver education standardizationand evaluation of therapeuticpositioning3536 The InfantPositioning Assessment Tool hasdemonstrated initial validity andreliability but has not been widelyimplemented353738 As the infantmatures and approaches readinessfor discharge from the hospital aninterdisciplinary collaborative andthoughtful approach is required todetermine how and when the use ofpositioning devices is discontinuedand removed from the infantrsquosbedding to achieve a safe sleepenvironment Additionallycommunication and education of theinfantrsquos caregivers and family arecrucial elements to avoid confusionconflicting information andinappropriate use of the devicesafter discharge from the hospital39

Many developmental care guidelinesinclude the AAP Safe Sleeprecommendations and encouragethe transition into a safe sleepenvironment for medically stableinfants after the age of 32 weeksrsquogestation and before discharge fromhospital to home26ndash28 However nospecific time frame has beenestablished to meet this goalleading to wide interpretation at thebedside1040ndash42 Some centers havedeveloped quality and processimprovement programs to establishmore concrete timing and increasedcompliance with the Safe Sleeprecommendations4344

Impact of Light and Noise Reductionon the Safe Sleep Environment

NICUs and special care nurseries canbe overstimulating to preterm andsick newborn infants Lighting noiseand temperature can be sources ofnoxious stimuli45ndash47 In an effort to

PEDIATRICS Volume 148 number 1 July 2021 3 by guest on September 2 2021wwwaappublicationsorgnewsDownloaded from

modify the external environment todecrease stressful stimulation manynurses and caregivers will place ablanket or other covering over theinfantrsquos head of the bed48 If not wellsecured these coverings couldbecome loose and cover the infantincreasing the risks of smotheringThe removal of loose blankets in thecrib is an important strategy towardimplementing a safe sleepenvironment12

Swaddling

The practice of swaddling infantshas been described in many culturesthroughout history49 Infantswaddling in which a cloth ordevice is wrapped around the infantto contain the infantrsquos body andextremities has been shown topromote sleep49 improve self-regulation particularly in preterminfants49 and decrease cryingtime50 Swaddling also has beenshown to promote supine sleepposition51 However inappropriateuse of andor tight swaddling canincrease the risks of developmentalhip dysplasia cause overheatingand restrict breathing It has beenassociated with vitamin Ddeficiency acute respiratory tractinfections and delayed regain ofbirth weight and may interfere withearly establishment ofbreastfeeding495253 There is amuch greater risk of SUID when aswaddled infant is placed in or rollsto the prone position54ndash56 Whenswaddled preterm infants should beplaced in the supine position havetheir hands brought to midlineunder the chin and hips and kneesshould be in the flexed position andable to move freely50 Term infantsespecially those with NOWS maybenefit from swaddling with armstucked in the swaddle to reducestartle response and prevent thehazard of loose blankets in escapingfrom the swaddle Because of therisk of SUID when swaddled infantsare in the side or prone position

swaddling should be discontinuedwhen the infant begins to attempt toroll over505556 For a moreextensive discussion about thepotential risks and benefits ofswaddling refer to the technicalreport ldquoSIDS and Other Sleep-Related Infant Deaths EvidenceBase for 2016 UpdatedRecommendations for a Safe InfantSleeping Environmentrdquo (currentlyundergoing revision)1

Skin-to-Skin Care

SSC or kangaroo mother care is thepractice of placing the infantrsquosunclothed chest against the motherrsquosunclothed chest for immediatecontinuous and sustained contactand exclusive breastfeeding57 SSCwas initially adopted as analternative to incubators incountries with limited resources inthe late 1970s and subsequentlydemonstrated improved survival forpreterm and low birth weightinfants58 Now widely adopted incountries with both limited andabundant resources the practice ofSSC has been shown to promotetemperature and blood sugarstability lower respiratory rateincrease oxygen saturation decreasesymptoms associated with mild tomoderate pain and promotematernal bonding and attachmentand breastfeeding These advantagesmay all contribute to overallphysiologic and neurobehavioraldevelopment2259ndash61 Howeversafety concerns have arisen with theincreased practice of SSCDislodgement of life supportequipment and dropping small andimmature infants falling out of bedand airway obstruction have allbeen reported When occurring inhealthy term or late preterm infantsthese events are referred to assudden unexpected postnatalcollapse which frequently results indeath or severe neurologicimpairment62 These unfortunatebut real events remind caregivers

and parents to be mindful andvigilant of the position of theinfantrsquos airway and the safety ofcaregiver holding to prevent fallswhen providing SSC2262 If this isundertaken in the NICU the infantshould be monitored and securedpreferably with a conforming wrapcarrier The parent should bepositioned in a recliner or approvedkangaroo care chair or hospital bedand the kangaroo care providershould be educated by staff abouthow this situation differs from thehome environment Because of theconcerns noted above and theknown dangers of sharing sleepsurfaces such as bed-sharing in thehome environment adults should bethoroughly educated about thedangers of sleeping during SSC

Conclusions RegardingDevelopmentally Sensitive Care

1 Developmentally sensitive care isan important component to thehealth and well-being of the pre-term infant

2 Many of the tools and therapiesused to promote developmentallysensitive care are not consistentwith a home safe sleep environment

3 It is important to transition in-fants to a home safe sleep envi-ronment well before dischargefrom the NICU

4 Good communication with the useof a multidisciplinary team is keyfor consistent transitioning of NICUpatients to a home safe sleep envi-ronment (see A Rational Approachto Transition of the NICU Patient toa Home Sleep Environment fordetails)

DEFORMATIONAL PLAGIOCEPHALY ANDTORTICOLLIS

Variations in head shape are oftenobserved in term and preterminfants in the NICU These headshape abnormalities can besecondary to nursing care practiceslimitations on positioning muscle


tone or other medical conditionsthat can lead to positional ordeformational plagiocephaly(DP)6364

Preterm infants are moresusceptible to developingplagiocephaly because of decreasedmineralization of the skull bones Inaddition they are more likely tohave been positioned prone whichmay be indicated when the infant ismedically unstable to decreasestress promote sleep improvefeeding tolerance and enhanceoxygenation and ventilationAlthough therapeutic positioning topromote medical stability takesprecedence during the acute phaseof illness whenever possible nursesshould make efforts to choosepositions that promote symmetricalcranial shape65ndash67

Since the early 1990s DP has beenincreasing in prevalence and isbeing more frequently diagnosedMost parents and health careprofessionals attribute this increaseto the supine sleep positionrecommended for infant safety68

although this has been challenged inrecent studies69ndash72 It was estimatedthat 466 of 7- to 12-week-oldinfants had nonsynostoticplagiocephaly (NSP) in a Canadiancohort study72 and in a Swedishstudy in 2009 42 of 2-month-oldinfants had some degree of NSP73 Ina prospective New Zealand studythere were significant multivariaterisk factors for NSP at 6 weeksincluding newborn passive headrotation (aOR 951 95 confidenceinterval [CI] 259ndash3494) 6-weeksleep position (aOR 527 95 CI181ndash1539) and upright time (aOR399 95 CI 142ndash1123) At 4months risk factors were limitedpassive head rotation at birth (aOR651 95 CI 185ndash2298) limitedactive head rotation at 4 months(aOR 311 95 CI 121ndash805)tried but unable to vary headposition at 6 weeks (aOR 428 95

CI 158ndash1159) low activity level at4 months (aOR 328 95 CI116ndash929) and average to difficultrating on the Pictorial Assessment ofTemperament test (aOR 330 95CI 117ndash929)70

Whether congenital musculartorticollis is the main predisposingfactor for DP remains controversialAlthough one study foundasymmetries of the head and neck tobe common in normal newborninfants and 16 (16) of 102 werefound to have torticollis at birth74

other recent studies suggest thatcranial shape is more oftendetermined by postnatal factors thanprenatal and perinatal factors andthat most concomitant cervicalimbalance (positional torticollis)develops postnatally along with DP75

DP results from unevenlydistributed external pressureresulting in abnormal head shapesMost cases involve unilateraloccipital flattening ipsilateral frontalbossing and anterior shifting of theipsilateral ear and cheek76 A rapidlygrowing head is malleable and mostsusceptible to deformation between2 and 4 months and declinesthereafter707277 Placing the infantrepeatedly on the same sideaccording to infant preferences aswell as slower motor developmentare risk factors for the developmentof DP In the NICU occupational andphysical therapists often make useof various positioning devices andsupports such as blanket rolls andcommercially available products toprevent progression and to correctDP and torticollis30ndash33 Howeverthese therapies are contraindicatedwhen the infant is getting closer todischarge from the hospital as theyare generally not consistent withhome infant sleep safetyrecommendations

Many infants with DP undergoadditional treatment at home Suchtreatments including physical

therapy need to be in line with safesleep recommendations Devicesthat promote a nonsupine sleepposition or have the potential tocompromise the airway are notappropriate The ldquoCongress ofNeurological Surgeons SystematicReview and Evidence-BasedGuideline on the Management ofPatients With PositionalPlagiocephaly The Role ofRepositioningrdquo stated that it cannotat this time endorse any sleeppositioning device because it wouldbe contrary to the repeatedrecommendations set forth by theAAP Task Force on Sudden InfantDeath Syndrome to avoid placingany soft surface bedding in theinfantrsquos crib78 Although orthotichelmet therapy can be difficult forthe parents and can cause sideeffects including sweating irritationand pain for the infant they canprovide significant and fasterimprovement of cranial asymmetryin infants with positionalplagiocephaly compared withconservative therapy The Congressof Neurologic Surgeons recommendsa helmet for infants with persistentmoderate to severe plagiocephalyafter a course of conservativetreatment or if the infant presents atan advanced age79

A recent randomized controlled trialin Finland evaluated the causalrelationship between DP andcervical imbalance (positionaltorticollis) The intervention groupwas given instructions to create anonrestrictive environment thatpromotes spontaneous physicalmovement and symmetrical motordevelopment77 The instructionsfocused on 3 areas alternating headposition laterally (left and right)during feeding and sleep avoidingexcessive awake time in supineposition (including prolongedplacement in car seats and otherdevices) in addition to using tummytime daily and preventing


restriction of movement Infant neckstretching exercises were performedby the parents if an infant showedsigns of muscular imbalance of theneck77 Infants in the interventiongroup were less likely to have DP atfollow-up and if present theasymmetry was milder In additioninfants who had DP were morelikely to have torticollis This studyconcluded that early interventionreduces the prevalence and severityof DP at 3 months77

The Finnish randomized controlledtrial was similar to a preventionproject among Swedish child healthnurses that incorporated a shortcranial asymmetry preventionprogram80 In this studyresearchers concluded thateducation of child health nurseswho in turn educate parents aboutNSP prevention is successful inincreasing parentsrsquo awareness ofsafe interventions to preventacquired cranial asymmetry80

These studies provide an evidence-based approach that the parents canuse to maintain the supine positionfor infant safety while decreasingthe risk of NSP andor DP andcervical imbalance (positionaltorticollis) For more information oncongenital muscular torticollis seethe 2019 AAP State of the Artreport Congenital MuscularTorticollis Bridging the GapBetween Research and ClinicalPractice81 For more information onDP see the Congress of NeurologicSurgeons Systematic Review andEvidence-Based Guidelines for thePatients With PositionalPlagiocephaly787982ndash84

Conclusions Regarding DP andTorticollis

1 DP and torticollis occur common-ly in the NICU environment

2 The preterm infant is especiallyat risk for DP because of de-creased mineralization of the

skull bones as well as moreprone and side positioning

3 Positioning devices recommendedby qualified personnel such asbut not limited to occupationaland physical therapists can beused to prevent control and cor-rect DP and torticollis while in-fants are under continuousmonitoring in the NICU

4 Parents need to be educated re-garding the use of sleep positioningdevices that their use is limited tothe inpatient setting under strictmonitoring and that they are notpart of a safe sleep environment

5 Orthotic helmets may be appro-priate for infants with persistentmoderate to severe plagiocephalyafter a course of conservativetreatment or if the infant pre-sents at an advanced age79

6 Parents should be educated toavoid excessive use of car seatsand infant positioning devicesthat can promote DP

7 Education regarding tummy timeshould emphasize that it be per-formed during awake supervisedperiods only and never when theinfant is asleep even with closesupervision

8 It is important to transition infantsto a safe sleep environment wellbefore discharge from the NICU

DEVELOPMENTAL DYSPLASIA OF THEHIPS

Clinical hip instability occurs in 1to 2 of term infants yet up to15 of term infants have hipinstability or immaturity detectableby imaging studies85 Developmentaldysplasia of the hip (DDH) whichwas previously called congenital hipdislocation is the most commonneonatal hip disorder and is nolonger considered congenital butdevelopmental in origin Theincidence of DDH is approximately 1to 21000 live births but thisestimate does not encompass theentire spectrum At birth aninvolved hip is rarely dislocated but

is dislocatable The clinicalsignificance depends on whether thehip stabilizes subluxates ordislocates and is dependent onmany factors including breechposition female sex incorrect lowerextremity swaddling and positivefamily history Breech presentationmay be the single most importantrisk factor DDH is reported to occurin 2 to 27 of boys and girlspresenting in breech position86ndash88

Other nonsyndromic findingsassociated with DDH include beingthe first born presence of torticollisfoot abnormalities andoligohydramnios8990

Many mild forms of DDH resolvewithout treatment The clinical hipexamination plus or minusabnormalities on ultrasonography willdetermine the need for an abductionbrace (frequently referred to as aPavlik harness) Potential risksassociated with the use of the Pavlikharness include aseptic necrosis of thefemoral head temporary femoral nervepalsy and obturator (inferior) hipdislocation889192 Stopping treatmentafter 3 weeks if the hip does notreduce and proper strap placementwith weekly monitoring are importantto minimize the risks associated withbrace treatment9394 Some cliniciansuse double or even triple diapering tomanage DDH although innocuous it isprobably ineffective95

Transitioning the NICU patient to asafe home sleep environment ofteninvolves swaddling which reducescrying and facilitates better sleep Inutero the infantsrsquo legs are in thefetal position with the knees bent upand across each other Suddenstraightening can loosen the jointsand damage the soft cartilage of thesocket Improper swaddling maylead to hip dysplasia and should beavoided in infants with thisdiagnosis Infants should never beplaced in prone or side positionswhile swaddled Proper hipswaddling techniques can be found


at httpshipdysplasiaorgwp-contentuploads202005HipHealthySwaddlingBrochurepdf

A leading proponent of swaddlingstates that contemporary swaddlingtechniques permit infants to besnugly wrapped with their hipsbeing safely flexed and abducted96

This position should be encouragedAn alternative method is to swaddleonly the upper extremities andallow the lower limbs to movefreely97 For a more extensivediscussion of the diagnosis andmanagement of DDH refer to theAAP clinical report ldquoEvaluation andReferral for DevelopmentalDysplasia of the Hip in Infantsrdquo85

Conclusions Regarding DDH

1 Infants are frequently swaddledin the NICU when approachinghospital discharge

2 Improper swaddling can lead toor exacerbate DDH

3 Proper swaddling techniqueshould allow the hips to be flexedand abducted

4 Parents should be well-educatedabout all safety issues regardingswaddling in particular the in-creased risk of SUID with nonsu-pine positioning

5 For more information refer tothe AAP clinical report on DDH85

RESPIRATORY DISTRESS (ACUTE ANDCHRONIC)

One of the most common reasonsfor admission to the NICU isrespiratory distress Some infantswill have acute respiratory distresswith rapid resolution such astransient tachypnea of the newbornand others will develop chronicrespiratory conditions such asbronchopulmonary dysplasia Someinfants will have respiratory distressfrom airway compromise or othersystemic problems affectingrespiration

It may seem counterintuitive toplace infants with respiratorydistress in the prone positionbecause it has been shown toincrease the risk of rebreathingexhaled gases which can result inhypoxia or hypercarbia98ndash101 Theprone position decreases the rate ofheat loss and increases bodytemperature putting the infant atrisk for overheating102103 Pronepositioning has been shown to alterautonomic regulation of thecardiovascular system especially inpreterm infants potentiallydecreasing cerebraloxygenation104ndash106 Pronepositioning also encourages longerand deeper sleep periods with fewerawakenings and behaviorsassociated with stress107108 TheSIDS triple risk hypothesis suggeststhat some infants who die becauseof SIDS had an intrinsic abnormalityin the brainstem that preventedappropriate arousal to anenvironmental threat All of theseelements (rebreathing overheatingand impaired sleep arousal) havebeen implicated in increased SIDSrisk However there is someevidence of potential respiratorybenefit with prone positioning

Acute Respiratory Distress

Once umbilical catheters areremoved one of the commonly usedinterventions to decreaserespiratory symptoms in thenewborn infant is prone positioningNumerous studies have beenperformed to understand whatcomponents of ventilation andoxygenation are affected by pronepositioning as well as the effects ofPMA and degree of illness (acuteversus chronic lung disease)Wagaman et al109 found that pronepositioning of preterm infants withacute respiratory disease resulted insignificantly improved arterialoxygen tension dynamic lungcompliance and tidal volumeImproved diaphragmatic excursion

may contribute to increased tidalvolume seen with prone positioningIn the supine position theabdominal contents can opposeexcursion of the diaphragm limitingventilation Improvement inoxygenation may be related toimproved ventilation-perfusionmatching In the supine positionsome lung tissue is dependent to theheart and mediastinal structuresincreasing the risk of atelectasis inthe unstable newborn lung109110 Inaddition to improved lung volumethere is evidence of lessintrapulmonary shunting andimproved thoracoabdominalsynchrony in the proneposition111112

In a Cochrane review113 from 2012researchers evaluated positioningfor acute respiratory distress inhospitalized infants and childrenusing data from 24 studies with atotal of 581 participants Althoughthe data combined studies of infantsand children 60 were preterminfants Seventy percent of the studyparticipants were evaluated whileon mechanical ventilation Resultswere limited because of lack of datafor many parameters smallparticipant numbers and shortstudy times There was a small butstatistically significant improvementin oxygenation (2 higher oxygensaturations) when positioned proneProne positioning also provided asmall improvement in tachypneawith a decrease of 4 breaths perminute

Although these results arestatistically significant they may beof marginal clinical relevanceHowever because the extremelypreterm infant will have a prolongedhospital course in the NICU thebenefit of prone positioning duringthe acute phase of respiratoryillness may outweigh the importanceof modeling safe sleep positioning atthat time Nonsupine positioning canstill be viewed as a teachable


moment between clinician andfamily Early safe sleep educationcan be incorporated intoexplanations as to why the infant ispositioned nonsupine during acuterespiratory distress

Chronic Respiratory Distress

Fewer data are available fordetermining any benefits of pronepositioning in the convalescentpreterm infant with resolvingpulmonary disease A small study of20 preterm infants (mediangestational age of 30 weeks range27ndash32 weeks) recovering fromrespiratory distress syndromeevaluated pulmonary mechanics at amedian postconceptional age of 35weeks114 In oxygen-dependentinfants oxygen saturations andfunctional residual capacity werehigher in the prone position butthere were no differences incompliance or resistance of therespiratory system In additionthere were no differences in any ofthe measurements for nonndashoxygen-dependent infants

In another study of healthy preterminfants approaching discharge withno history of respiratory distressthere was no effect of prone versussupine positioning regardingrespiratory rate tidal volumeminute ventilation lung compliancepleural pressure or inspiratoryelastic and resistive work ofbreathing115 Other studies haveshown conflicting resultsHutchinson et al found increasedtidal and minute volumes but alsoincreased work of breathing in latepreterm infants in the proneposition116 Elder et al found noimpact of position on oxygensaturations in preterm infantsapproaching hospital discharge117

Leipala et al118 found an increase intidal volume but lower respiratorymuscle strength in the pronecompared with the supine positionin preterm infants studied

immediately before discharge fromthe hospital

The contradiction of improvedrespiratory function for somepreterm infants with the decreasedrisk of SIDS or sleep-related deathsmust be resolved or as Poets andvon Bodman119 noted we are leftwith a ldquocognitive dissonanceotherwise resulting from parentsseeing their infant being nursed inthe prone position for several weekswhile being told that they mustplace their infant supine once athomerdquo119 At some point thediminishing benefits of pronepositioning are outweighed by therisk of SUID a leading cause ofpostneonatal mortality Clearly thisneeds to be addressed well beforedischarge from the NICU

Upper Airway Obstruction

Numerous congenital abnormalitiesof the airway can result inrespiratory compromise PierreRobin sequence can be particularlychallenging in regard to infant sleepsafety because of the gravity-dependent tongue-basedobstruction120 For infants on themildest end of the spectrum who donot experience significant airwayobstruction while in the supineposition and have normal arterialsaturations and adequate gasexchange there is no need todeviate from standard safe sleeprecommendations In the 40 ofcases that are severe120 infants willrequire an inpatient surgicalintervention such as mandibulardistraction osteogenesis tongue-lipadhesion or tracheostomy resultingin a stable airway in supine positionat discharge However theintermediate cases are moreproblematic because they are notsevere enough for early surgicalintervention but require the side orprone position for a stable airwayIn these cases it may be appropriatefor an infant to sleep on the side or

in prone position with considerationof using a home monitor with orwithout pulse oximetry Althoughhome monitoring does not preventor reduce the risk of SUID and is notrecommended for that purpose inthis situation monitoring includingconsideration of pulse oximetry isappropriate for limiting airwayobstruction which could lead tohypoxic injury or death Regardlessthese infants should be managed bya specialized team proficient in thecare of such disorders

Conclusions Regarding RespiratoryDistress

1 For the infant with acute respira-tory distress regardless of gesta-tional age nonsupine positioningmay be used as clinically indicat-ed to stabilize andor improverespiratory function

2 If nonsupine positioning is usedespecially as the infant maturesparents should be educated aboutinfant sleep safety and the rea-sons for deviating from homesafe sleep recommendations

3 Once the acute respiratory distressis resolving the infant should beplaced supine for modeling homesafe sleep and the parents shouldreceive additional education beforehospital discharge

4 For infants who have developedchronic lung disease periodic as-sessments can be performed tomonitor the infantrsquos progress Oncethe infant has weaned to a standard-ized minimal supplemental respira-tory support (determined by theindividual institution) then supinepositioning can be maintained andparents should receive additionaleducation before hospital discharge

5 Management of the infant withupper airway obstruction needsto be individualized on the basisof the severity of the obstructionNonsupine positioning may benecessary to prevent excessivehypercarbia or hypoxemia


Consideration should be given tohome monitoring of the marginalairway

APNEA OF PREMATURITY

Infant apnea is defined by the AAPas ldquoan unexplained episode ofcessation of breathing for 20seconds or longer or a shorterrespiratory pause associated withbradycardia cyanosis pallor andormarked hypotoniardquo121 Apnea can beclassified as central obstructive ormixed on the basis of airflow andrespiratory effort The incidence ofapnea is inversely proportional togestational age Although all infantsborn at less than 28 weeksrsquogestation will have recurrent apneathe incidence decreases to 20 by34 weeksrsquo gestation and theseevents resolve in 98 of infants by40 weeksrsquo PMA122 It is unclear as towhat degree of apnea is consideredacceptable and there is concernabout the long-termneurodevelopmental effects ofrecurrent apnea and periodicbreathing on the preterm infantMeasurements of cerebraloxygenation using near-infraredspectrophotometry havedemonstrated decreases in tissueoxygenation during apneic events inpreterm infants both late inhospitalization and up to 6 monthsrsquopostterm corrected age105 It hasbeen suggested that intermittenthypoxia resulting from continuingapnea and periodic breathing cancause hypoxic cerebral injury123 andworsening of neurodevelopmentaloutcomes124125

Some research has suggested thatuse of the prone position mayreduce apnea frequency andorseverity In a small study of 35preterm infants that used acrossover design placing each infantsupine and prone there weresignificantly more central and mixedapneas in the supine position126 Inaddition during mixed apneas there

were greater decreases in heart rate(P 5 02) longer duration ofbradycardia (P 5 0003) and longeraccompanying desaturations (P 503) when infants were in the supineposition In another small crossoverdesign study of 14 stable preterminfants there was no positionaldifference in the incidence ofbradycardia but there was anincrease in apnea density defined asthe number of episodes lasting gt6seconds during quiet sleep (45 vs25 P 5 01) and periodic breathing(percentage of quiet sleep 136 vs77 P 5 015) when infants werein the supine position127

In more recent studies researchershave found either no positionaldifferences in the incidence of apneaor bradycardia or a reduction inalarms with supine positioning128129

Bhat et al found preterm infants inprone position to have more centralapneas (median 56 vs 22 P 5 04)but fewer obstructive apneas (05 vs09 P 5 007) While supine theinfants had more awakenings (97 vs35 P 5 003) and arousals per hour(136 vs 90 P 5 001)129 Thesestudies were also limited by smallsample size A 2017 Cochrane reviewidentified 5 eligible trials totaling 114infants in which no statisticaldifferences were identified betweensupine and prone positioning withregard to the frequency of apneabradycardia or oxygendesaturations130 The overall qualityof evidence was low and thereviewers concluded that theyldquocannot recommend use of one bodyposition over another forspontaneously breathing preterminfants with apneardquo For additionalinformation on apnea of prematurityrefer to the AAP clinical reportApnea of Prematurity131

Home Monitors

Home monitors are frequently usedin the NICU setting to allow forearlier discharge of infants with

mild persistent apnea ofprematurity However they have notbeen found to be protective againstSUID and are not recommended forthis purpose In addition the use ofnonndashmedical-grade monitors hasincreased in popularity As per taskforce recommendations1 parentsshould be educated that no monitortakes the place of following the safesleep recommendations

Conclusions Regarding Apnea andProne Positioning

1 There is inadequate evidence tojustify the use of prone position-ing for the treatment of apnea ofprematurity

2 For more information on apneaof prematurity refer to the AAPclinical report on apnea ofprematurity131

GASTROESOPHAGEAL REFLUX DISEASE

GER is a normal developmentalprocess that involves theinvoluntary passage of gastriccontents into the esophagus GERepisodes are usually brief with littleor no symptoms Many healthy terminfants have 30 or more episodesper day of GER and are known asldquohappy spittersrdquo Generally theseepisodes dissipate over the first yearof life as the smooth muscle of thelower end of the esophagusincreases in tone with maturationThese episodes of GER are classifiedas transient lower esophagealsphincter relaxations132133 whereaspathologic GER or gastroesophagealreflux disease (GERD) involves signsand symptoms of esophagitis withreflux into the esophagus oralcavity andor airways Putativemorbidities of GERD in preterminfants include frequent vomitingaspiration pneumonia irritabilityfailure to thrive and exacerbationsof respiratory symptoms134 GERand GERD probably represent 2ends of a spectrum of the same


condition varying with the severityof the gastric reflux134135

As feeding volume increases andorabdominal straining occurs thelikelihood of acid reflux episodesincreases132 The presence of anasogastric or orogastric tube mayalso contribute to GER because itspresence impairs the ability of thelower esophageal sphincter tocompletely close especially in thefirst postprandial hour136137

Esophageal motility transit timeand gastric emptying are known tobe slower in the preterm infant Fullmaturation of the intestinal motorfunction does not occur for severalmonths Contractions of thegastrointestinal tract with feedingsare neurally regulated butmodulated by gastrointestinal tracthormones138

Small enteral feedings (20ndash24 mLkg per feeding) produce a moremature motor pattern validated byimproved feeding tolerance andfaster gastric emptying andintestinal transit time139

Approximately 80 of infants withuncomplicated GER will improvewith conservative measures aloneincluding small frequent feeds andholding the infant upright for 20 to30 minutes after feeding If presentremoval of a nasogastric ororogastric tube may also improvesymptoms of GER137140

In term infants GER symptoms canbe abated by avoidance ofoverfeeding and exposure to tobaccosmoke change of formula and theuse of thickened feeds141

Thickening of human milk withstarch is problematic because theviscosity decreases over timebecause of amylase in the milkwhich degrades the starch in thethickener142 Care should be takenwith thickening feeds for preterminfants because a xanthan gumproduct has been linked to late-onset necrotizing enterocolitis143 In

addition commercially availableformulas that thicken onacidification in the stomach are notnutritionally optimal for the preterminfant Although there is no reasonto suspect that thickening of feedswould work differently in pretermas compared with term infantsthere are few data showing theefficacy of thickened feeds in thispopulation4

According to Salvatore andVandenplas in 2002 as many as15 to 40 of infants with GER orGERD have a cow milk proteinintolerance or dietaryproteinndashinduced gastroenteropathyAfter the neonatal period a trial ofan elemental formula may beindicated in infants younger than 1year if a cow milk proteinintolerance is suspected144 Forinfants receiving human milksimilar improvement can beobtained by restricting all dairyincluding casein and whey in themotherrsquos diet141 Cow milk proteinintolerance is most often diagnosedin infants on the basis of theirsymptoms and how they respond todietary changes There is evidenceto support a trial of an extensivelyhydrolyzed protein formula for 2 to4 weeks in term infants but if noimprovement occurs with thisdietary change the infantrsquos normaldiet can be resumed

In the preterm infant thepersistence of symptoms despiteholding the infant upright for 20 to30 minutes small frequent feedsand removal of the nasogastric ororogastric tube if feasible oftenleads to the use of therapeuticinterventions such as side-lying andelevation of the head of the bedThere is no benefit to elevating thehead of the bed and it should beavoided especially after dischargebecause it may actually increase therisks of SUID145 Often acombination of pH and electricalimpedance monitoring is used to

evaluate the effect of bodypositioning on GER andGERD145ndash148 Placing the preterminfant in the left lateral positionafter feeding versus right lateralposition and placing the infantprone versus supine may decreaseGER episodes147149150 Althoughplacement of the infant in the rightlateral position may increase GERepisodes it may promote gastricemptying150 Prone and lateralpositioning of infants from birth to12 months is associated with anincreased risk of SUID and shouldbe avoided The risks associatedwith prone andor lateralpositioning outweigh any benefitgained Multiple studies in differentcountries have not shown anincrease in the incidence ofaspiration since the change tosupine sleeping151ndash153

Despite the evidence againstaspiration in the supine positionmany parents and caregivers remainunconvinced154ndash162 Coughing orgagging is misconstrued asaspiration although it representsthe normal protective gag reflexThe AAP concurs with the NorthAmerican Society for PediatricGastroenterology Hepatology andNutrition that the risk of SUIDoutweighs the benefit of prone orlateral sleep position on GERTherefore most infants from birthto 12 months of age should bepositioned supine during sleepElevating the head of the infantrsquoscrib while the infant is supine is noteffective in reducing GER163164 Ifthe head of the bed is elevated theinfant may slide into positions thatmay compromise the airway andresult in the death of the infant

In the 1980s the US Food and DrugAdministration had approvedseveral devices to reduce GER orpositional plagiocephaly Howeverafter reports to the ConsumerProduct Safety Commission (CPSC)of a number of deaths the Food and


Drug Administration requiredmanufacturers to demonstrate thatthe product benefit outweighed therisk of suffocation165 Manymanufacturers dropped their claimsof medical benefit but devicescontinued to be sold by retailersdirectly to the public asnonndashmedical-grade devices

In 2019 inclined sleepers (whichare frequently advertised as beingbeneficial for infants with GER)came under additional scrutiny aftera series of deaths were reported tothe CPSC and additional deaths wereuncovered in a Consumer Reportsarticle166 Major manufacturersvoluntarily recalled their productsThe CPSC issued a statement for asupplemental proposed rule(Supplemental NPR) proposing toadopt the current ASTMInternational standard for inclinedsleep products with modificationsthat would make the mandatorystandard more stringent than thevoluntary standard The proposedchanges include limiting the seatback angle for sleep to 10 degreesor less167

Often health care providers arepressured to elevate the head of thebed andor provide pharmacologicinterventions despite the lack ofevidence supporting these practicesA recent study demonstrated thatinfants could more easily roll fromsupine to prone in an inclinedsleeper and once in the proneposition they would fatigue fasterthan they would on a stable flatsurface because of the highmusculoskeletal demands necessaryto maintain safe posture to preventsuffocation168 The study also foundthat prone positioning on aninclined sleep surface places theinfant at higher risk of airwayobstruction or suffocation asevidenced by oxygen saturationresults These results may provide amechanism to some of thesuffocation deaths related to car

seats and other sitting and carryingdevices169

Safe sleep is paramount duringmaturation of the lower esophagealsphincter which will abate thesymptoms of GER with timeTherefore supine positioning is thepreferred safe sleep position forinfants with GER or GERD For amore extensive discussion of GERand GERD in the preterm and younginfant see the AAP clinical reportldquoDiagnosis and Management ofGastroesophageal Reflux in PretermInfantsrdquo4 or the ldquoPediatricGastroesophageal Reflux ClinicalPractice Guidelines JointRecommendations of the NorthAmerican Society for PediatricGastroenterology Hepatology andNutrition and the European Societyfor Pediatric GastroenterologyHepatology and Nutritionrdquo141

CONCLUSIONS REGARDING GER ANDGERD

1 GER is extremely common in in-fants in the NICU

2 Because of the increased risk ofSUID infants should not have thehead of the bed elevated norshould they be laid down on theirside or prone

3 Term infants can be treated withsmall frequent feeds holding theinfant upright after feedingthickened feeds elemental for-mula and removal of the naso-gastric or orogastric tube whenappropriate If the mother is pro-viding human milk elimination ofall cow milk protein from herdiet may be beneficial

4 Preterm infants can be treated asabove but care should be takento avoid commercial thickenersbecause of the association withnecrotizing enterocolitis

5 For more information refer tothe AAP clinical report on GER inthe preterm infant (ldquoDiagnosisand Management of

Gastroesophageal Reflux in Pre-term Infantsrdquo4)

THERMOREGULATION

Temperature regulation in thenewborn infant is frequentlyreferred to as being immature atbirth secondary to the lack ofcompletely developedthermoregulatory mechanismsincluding large surface area-to-volume ratios and the relativelysmall insulating body shell170 As aresult of this immaturity neonatesdo show greater fluctuations of bodytemperature and difficulty inachieving acceptablethermoregulation

It is well-established that preventionof hypothermia and achievingnormothermia in newborn infantsdecreases mortality and optimizesoutcomes Achieving a neutralthermal environment is the goal forevery patient in the NICU Achievinga neutral thermal environmentrequires that thermoregulatorycontrol be a balance between heatproduction and heat loss Measuresto achieve this goal include dryingthe infant at birth providingwarmth and insulated surfaces asneeded providing radiant heat andavoiding cool air currents Inaddition humidity is routinely usedin incubators in the NICU Certainclinical scenarios require chemicalmattresses and polyethylene wrapsor bags to prevent heat loss171172

Hats are also routinely used in thedelivery room to reduce heat lossEstimates of heat loss from the headand face of the newborn infant varybut have been reported at up to85173 Some estimates based onstudy of clothed adults may besignificantly inflated An infantsimulation study using a heatedmannequin model found wearing ahat decreased the local heat loss byan average of 189 in all clothedand thermal conditions174 The typeof hat used to reduce heat loss is


important A simple stocking net hathas been shown to provide minimalimprovement in temperature175

Although data are inconsistent apolyethylene hat has been shown tobe more effective in preventing heatloss in the delivery room forpreterm infants176 In a small studyresearchers found a cotton-wool(Gamgee) material reduced heat lossin term infants177

Although preterm infants cannotregulate their body temperature aswell as term infants theirthermoregulatory ability improveswith maturation178 Weight-basedcriteria for weaning out of theincubator to a cot or bassinet variesfrom center to center179ndash181 ACochrane review in 2011 concludedthat transfer to a cot when theinfant attained a weight of 1600 gdid not have adverse effects ontemperature stability or weight gainand earlier weaning from theincubator did not necessarily lead toearlier discharge182

Discharge readiness is usuallydetermined by demonstration offunctional maturation including thephysiologic competencies ofthermoregulation178 Often theability to increase metabolism andgenerate heat reaches that of theterm infant before 40 weeksrsquo PMAwhich is reassuring at the time ofdischarge planning from the NICUProne sleeping infants have areduced ability to lose heat whichcan lead to overheating102 Evidencepoints toward probable differencesin autonomic control of metabolismand cardiorespiratory function inthe prone versus supine position170

Nonetheless overheating as well asprone positioning is anindependent risk factor for SUIDand must be avoided1 Althoughstudies have shown an increasedrisk of SUID with overheating thedefinition of overheating has variedmaking it difficult to recommend aspecific room temperature

guideline to avoidoverheating183184

Infants should be dressedappropriately for theenvironment175ndash177 In term infantsthis is usually 1 layer more than anadult However there is significantvariation in how preterm infants aretransitioned from the incubator tothe open crib including weightcriteria PMA number of layers ofclothing provided and use ofwearable blankets and hats179180 Inone study infants were placed inthe bassinet with 2 layers ofblankets or a sleep sack and ahat180 Although the focus duringtransition to the open bassinet is onprevention of hypothermia once theinfant demonstrates temperaturestability providers should turn theirattention to modeling safe sleep andthe dangers of overheating andoverbundling Infants are safestwhen they do not sleep withblankets173185 If there is concernthat the infant will become cold aninfant sleeping bag sleeping sack orwearable blanket is recommendedas an alternative to blankets Whenusing a sleeping bag special careshould be taken with the preterminfant to ensure they cannot slipinside and that the head cannotbecome covered186 Some wearableblankets come with a swaddlefeature There is no evidence torecommend swaddling (wrapping theinfant in a light blanket or wearableblanket with a wrap) as a strategy toreduce the risk of SUID1 Refer to thesection on developmentally sensitivecare for a discussion of the risks andbenefits of swaddling

Parents andor caregivers should beeducated on evaluating the infantfor signs of overheating includingsweating or the chest feeling hot tothe touch1 Overbundling andcovering of the face and head shouldbe avoided173 Head covering isassociated with an increased risk ofSUID This increased risk with head

coverings generally refers tocovering with bedding or bedclothes Only one study refersspecifically to hats finding thatalthough the majority did not wearhats there were significantly morehat-wearing infants among the SIDSinfants compared with the controlinfants187 A systematic review of 10population-based age-matchedcontrolled studies found the pooledprevalence of head covering in SIDSvictims was 246 compared with32 of controls The causalmechanism of this increased riskremains unclear but hypoxiarebreathing and thermal stress havebeen hypothesized asmechanisms173 Although it may beunlikely that dislodgement of a hatcould lead to obstruction of aninfantrsquos airway there may belegitimate concern regarding theircontribution to overheating andorthermal stress A recent articlequestioned the necessity of hats forpreterm infants after initialstabilization188 A chart review of729 infants transitioned out ofsupplemental heat without the useof hats found a failure rateattributable to hypothermia of 27Given the questionable benefit of hatuse and the potential for harmclinicians should weigh the riskbenefit ratio in regard todischarging an infant from the NICUwith a hat If the infant is dischargedwearing a hat the clinician shouldprovide instruction for families todiscontinue use once the infantdemonstrates stable temperatures inthe home environment This shouldinclude education about how todetermine that the infantrsquostemperature is stable

CONCLUSIONS REGARDINGTHERMOREGULATION

1 Preterm and low birth weight in-fants are prone to temperatureinstability and may require


additional bundling to avoidhypothermia

2 Excessive bundling should beavoided because overheating andhead covering have been associ-ated with an increased risk ofSUID

3 If an infant is discharged wearinga hat families should be coun-seled to discontinue its use oncethe infant demonstrates tempera-ture stability in the homeenvironment

4 If swaddling is performed it isimportant that it is done proper-ly the infant is always placed su-pine and it is discontinued whenthe infant begins to attempt toroll

HYPERBILIRUBINEMIA ANDPHOTOTHERAPY

Hyperbilirubinemia is an extremelycommon problem in both the termand preterm infant During the firstweek of life up to 60 of termnewborn infants and 80 ofpreterm infants will developjaundice because of the immaturityof the liver leading to elevatedconcentrations of circulatingunconjugated bilirubin189 Beyondthe common physiologic jaundice ofthe newborn infant there are manyhemolytic conditions and otherabnormalities that can lead toexcessive jaundice Nomograms areavailable to help the clinician detectwhich term and late preterm infantsare at higher risk of going on todevelop excessive jaundice thatuntreated could lead to kernicterusand permanent bilirubinencephalopathy190

The mainstay of therapy forneonatal unconjugatedhyperbilirubinemia is phototherapyThe factors that affect the dose ofphototherapy are the irradiance ofthe light used the distance from thelight source and the amount of skinexposed189 The infant should benaked except for diaper and eye

protection The phototherapy doseincreases as the distance from thelight to the infant decreasesSpectral power increases as theamount of skin exposed tophototherapy increases and can bemaximized by using a phototherapyblanket under the infant while usingphototherapy lamps over the infant

When using standard phototherapyunits many providers choose torotate the infant between supineand prone positioning Several smallstudies have been undertaken toevaluate the utility of changing theposition of the neonate duringphototherapy and no benefit inrelation to decrease in bilirubinconcentrations was found191ndash193 Allrecent studies have been evaluatedin a systematic review that alsoconcluded that supine positioning isas effective as turning infantsperiodically192 Two more recentand larger trials provide additionalevidence suggesting that positionalchange is unnecessary for successfuluse of phototherapy Donneborgincluded infants as young as 33weeksrsquo gestation and used higherlight irradiance compared with olderstudies193 The study demonstratedidentical rates of decrease in totalserum bilirubin at 12 and 24 hoursafter initiation of phototherapyregardless of supine or alternatingpositioning Most recentlyBhethanabhotla et al194 studied 100infants of greater than 34 weeksrsquogestational age and found nodifference with or withoutpositioning in the duration ofphototherapy or the rate of decreasein total serum bilirubinconcentration

Although the AAP guidelineldquoManagement of Hyperbilirubinemiain the Newborn Infant 35 or MoreWeeks of Gestationrdquo did notcomment on positioning of theinfant during phototherapy there isan analysis and statement from theUnited Kingdomrsquos National Institute

for Health and Clinical Excellence(NICE) on this issue195 The NICEGuideline Development Groupaccepted that in term infants theposition of the infant duringphototherapy has no significantinfluence on duration ofphototherapy or mean change inserum bilirubin concentration Itconcluded that to ensure consistentadvice regarding the risk of SIDSinfants should be placed in a supineposition195

The NICE recommendation did notinclude preterm infants because itwas released before the most recentstudies that included infants as earlyas 33 weeksrsquo gestation However theconsistency of the results in bothterm and middle-to-late preterminfants should provide clinicianswith confidence in maintaining theseinfants in a strictly supine position ifthere is no other contraindicatingmedical condition Modeling thesupine position is a powerful tool inthe education of families regardinginfant sleep safety and SUID riskreduction These more maturepreterm and term infants are likelyto have short stays in the NICU soearly modeling of safe sleep is morepressing and the use ofphototherapy should not interferewith supine sleep positioning196

CONCLUSIONS REGARDINGPHOTOTHERAPY

1 Hyperbilirubinemia and the useof phototherapy is common interm and preterm infants in theNICU

2 There is no benefit to changingan infantrsquos position while underphototherapy However the pro-vider may choose to place the in-fant on a bilirubin blanket inaddition to an overhead photo-therapy unit if the absolute totalserum bilirubin concentration isincreasing rapidly in effect


performing double-sidedphototherapy

3 Unless there are other competingmedical issues infants should bekept supine while receiving pho-totherapy to model and promoteinfant sleep safety

NEONATAL OPIOID WITHDRAWALSYNDROME

NOWS is a clinical conditionobserved in neonates experiencingwithdrawal from in utero opiateexposure197 Symptoms caused bycentral nervous system irritabilityautonomic nervous systemdysfunction and gastrointestinaland respiratory tract distresstypically appear 2 to 3 days afterbirth and can last for weeks ormonths197 Although opiatereplacement therapy may beindicated on the basis of theseverity of clinical presentation thefoundation of treatment and supportof the infant with NOWS is directedat supportive nonpharmacologiccare aimed at minimizing thestimulation that is beingexperienced andor supporting theinfant to self-regulate198199 Thesemeasures include promoting SSC200

rooming-in and breastfeeding201ndash203

decreasing light and noise200

swaddling and positioning200 use ofpacifiers andor rockers200 andmassage200 Many of theseinterventions commonly associatedwith developmentally sensitive carepreviously described in this reporthave variably been shown to helpsupport preterm infantsrsquoneuroregulation decrease length ofmedical treatment and decreasehospital length of stay198200203

Despite a paucity of evidence theseinterventions are being used to helpsupport infants struggling withNOWS198200203

SSC has been recommended as astrategy to help support infants withNOWS for many of the same reasonsas previously mentioned in this

article such as improved neurologicregulation establishment ofbreastfeeding and maternalbonding200 One of the benefits ofSSC is to enhance breastfeeding204

which in turn has been shown todecrease the severity of NOWSsymptoms days of pharmacologictreatment and hospital stay198205

Current recommendations supportbreastfeeding when the mother iscompliant with maintenancetherapy197

The importance of not falling asleepwith the infant during SSCespecially after hospital dischargeshould be stressed with opioid-dependent parents The opioid-dependent parent falling asleep withthe infant would be analogous tobed-sharing with someone who isimpaired in his or her alertness orability to arouse because of sedatingmedications which greatly increasesthe risk of SIDS1 Falling asleep withthe infant during SSC is of particularconcern for the mother of an infantwith NOWS because duringpregnancy women often requireincreases in methadone dosingbecause of factors such as increasedintravascular volume and increasedtissue reservoir and hepaticmetabolism of the drug206 Theoptimal approach to methadonedose management in the postpartumperiod however is not well definedand there is the theoretical concernthat methadone concentrations mayincrease as plasma volume andhepatic clearance return to theprepregnant state Yet in a study of101 methadone-maintainedpregnant women researchers foundno significant increase inoversedation events after adjustingfor benzodiazepine prescriptionsthe incident relative rate of an eventamong postpartum womencompared with pregnant womenwas 174 (95 CI 056ndash530)206

Nevertheless opioid exposure is stillof concern because a retrospective

study has implicated opiates insudden infant death with maternalmethadone use identified in 31 of32 neonatal deaths evaluated byautopsy207 It is unclear whether thedeaths were directly related to themethadone or other environmentalfactors In addition the frequentoccurrence of polysubstance use (egtobacco and alcohol) among thosewho use opioids further increasesthe risk of sudden infant deathparticularly associated with bed-sharing208ndash210 Thus presence ofmaternal substance use disorderwarrants extensive safe sleepeducation before discharge from thehospital

Swaddling is frequently used in thecare of infants with NOWS andseems to be an effective therapeuticintervention for this populationAlthough no studies specificallyaddress swaddling and infants withNOWS it is believed theintervention may be useful todecrease excessive crying andpromote sleep198199211 Refer to thesection on developmentally sensitivecare for additional information onbenefits and risks of swaddling

Swings and motion devices arecommonly used in NICUs wellnewborn units and pediatricinpatient units to calm fussy infantsparticularly those suffering fromNOWS Rocking devices have beenused through the ages for theircalming effect on crying infantsAlthough not extensively studiedthere are reports demonstrating theconsoling effect of rocking212213

The data are inconsistent regardingdirection of the movement and onestudy showed more benefit byrocking at 60 cycles per minuteversus 45 cycles per minute213 Arecent study showed benefit ofrocking by either a parent ormechanical device although rockingby the parent appeared to be moreeffective214 It is important that staffuse motion devices appropriately


while infants are awake andproperly monitored In additioninfants should be moved to a safesleep environment if they fall asleepin a swing or motion device becausethese are not considered safe sleepsurfaces Although infants are underconstant monitoring in the NICUenvironment leaving a sleepinginfant in a swing or motion device ispoor modeling for families andundermines safe sleep messaging

There is some evidence that placinginfants who are experiencingnarcotic withdrawal in the proneposition decreases the severity ofNOWS scores as well as caloricintake215 As described previously inthis article prone positioning mayincrease the risks of musculoskeletalabnormalities108 as well as SUID isnot consistent with AAP safe sleeprecommendations and is notrecommended as a strategy toconsole infants with NOWS outsideof a monitored unit Pronepositioning may be useful formonitored inpatients during theacute withdrawal phase of NOWSbut should be discontinued andthe patient should be placed insupine position as soon as possibleand before discharge from thehospital

The time that the infant may needthese interventions focused onneurodevelopmentally sensitive carewill depend on the length andseverity of NOWS symptomsParticularly in infants whose NOWSsymptoms seem to worsen withoutthese interventions transition tosafe sleep practices before dischargefrom the hospital often presentschallenges to NICU clinicians andfamilies Each center caring forinfants with NOWS should developand implement a standardizedprocess to identify when the infanthas reached medical stability andtransition to safe sleeprecommendations before dischargefrom the hospital

CONCLUSIONS REGARDING NOWS

1 There are some commonly usedinterventions in the treatment ofNOWS (ie prone positioning) thatare not consistent with home in-fant sleep safety

2 Early and frequent education iscritical to prevent families fromthinking that therapeutic inter-ventions in the hospital that arenot consistent with home infantsafe sleep guidelines can be repli-cated in the home environment

3 The use of therapeutic interven-tions that are not consistent withhome infant sleep safety shouldbe minimized When they arenecessary it is important to re-view their use and transition to asafe sleep environment as earlyas possible

4 Clear consistent safe sleep mes-saging should be emphasizedwith families of infants withNOWS well in advance of dis-charge from the hospital

HUMAN MILK AND BREASTFEEDING

Although not directly related to thetransition to safe sleep a discussionabout infant sleep safety is notcomplete without mentioningbreastfeeding and human milkfeeding The benefits ofbreastfeeding are numerousincluding decreased risk of infectiondecreased risk of allergies asthmaand eczema decreased risk ofobesity inflammatory bowel diseasehigh cholesterol and type I diabetesmellitus and possibly decreased riskof some childhood cancers216 Inaddition in preterm infants humanmilk has been shown to improvefeeding tolerance and reduce therisk of necrotizingenterocolitis217ndash220 Multiple studieshave shown that breastfeeding isassociated with a decreased risk ofSUID221ndash223 A recent meta-analysisfound that providing term infantswith any human milk for at least thefirst 2 months of life decreased the

risk of SUID by 40 (relative risk060 [044ndash082])224

The reduction in risk of SUID fromhuman milk may be multifactorialHuman milk has biologically activecomponents that areimmunoprotective through theirantimicrobial andimmunomodulatory activity Amongthe many components are whiteblood cells stem cellsimmunoglobulins (especiallysecretory immunoglobulin A)lactoferrin lysozyme and humanmilk oligosaccharides225226 Thedecrease in viral infections (whichhave been associated with anincreased risk of SUID1) maypartially explain this protectiveeffect of human milk In additionpolyunsaturated fatty acids inhuman milk in particulardocosahexaenoic acid are importantin the overall maturation of thecentral nervous system especiallythe cardiorespiratory center andmyelination of the brain227ndash230 Inone study infants who died of SIDShad delayed myelination of the braincompared with control infants231

Given the increased risk of SUID inthe preterm infant breastfeedingand the use of human milk afterdischarge may be even moreimportant in this populationHowever successful maternal milkproduction is dependent on earlyinitiation and in the case of thepreterm or term infant withrespiratory distress it requires themother to provide expressed milkthrough pumping or handexpression As a result cliniciansneed to provide education regardingthe benefits of breastfeeding onadmission to the NICU or earlier ifpossible232 and work inmultidisciplinary teams to enhancesupport for breastfeeding milkexpression and provision ofmotherrsquos milk throughout the NICUstay233 Furthermore preterminfants and their mothers require


significant support when they aredischarged from the hospital andtransition to direct breastfeeding inthe home setting234

Finally as noted in the previousdiscussion on SSC it is critical thatparents be aware of the dangers offalling asleep with their infant Thisis especially important whenmothers are rooming-in with theirinfant and not under constantobservation by NICU staff Althoughit is often stated that breastfeedingnaturally results in maternaldrowsiness from the release ofprolactin and oxytocin there arefew data to support thisconcept235236 Breastfeedingmothers are often exhausted in theearly days and weeks from sleepdeprivation and disruptions in theirnormal circadian rhythms In a 2019study researchers found that afterdelivery new mothers averaged 37hours of sleep and the longestinterval of sleep observed wasbetween 2 and 3 hours throughoutthe postpartum hospital course237

Of the 101 participants 50 requiredat least 1 intervention or correctiveaction to address unsafe sleep237

Mothers may also be emotionally orphysically exhausted from the stressand other demands of a NICUhospitalization238 The risks forinfant falls or smothering areanalogous to those seen withrooming-in on the well newbornunit with healthy mother-infantdyads Studies have observedassociations between postpartumsleepiness and fatigue and decline incognitive neurobehavioralfunctioning239240 Education of staffand families is crucial and staffshould also take care to evaluate themotherrsquos level of sleepiness238241

The risk of falls and suddenunexpected postnatal collapseshould be minimized by conductingfrequent assessments andmonitoring of the mother-infantdyad and evaluating the level of

maternal fatigue If the mother orcaregiver is tired or sleepy whileholding the infant the infant shouldbe moved to a separate sleepsurface62

This can be an opportunity for opennonjudgmental discussion regardingthe familyrsquos infant sleep safety planfor home The AAP 2016 policystatement on SIDS recommendsroom-sharing with the infant on aseparate sleep surface2 The policyalso states numerous conditionsunder which bed-sharing isparticularly dangerous And even insituations in which there are noother risk factors there is someevidence of increased risk with bed-sharing especially in the youngestage groups and among those whowere born preterm or with lowbirth weight Sample size limitationsprevent a determination of howlarge that risk is but clearly thedata do not support a definitiveconclusion that bed-sharing in theyoungest group is safe even underless hazardous circumstances Foradditional information refer to boththe AAP clinical report ldquoSafe Sleepand Skin-to-Skin Care in theNeonatal Period for Healthy TermNewbornsrdquo62 and AAP technicalreport ldquoSIDS and Other Sleep-Related Infant Deaths EvidenceBase for 2016 UpdatedRecommendations for a Safe InfantSleeping Environmentrdquo1

CONCLUSIONS REGARDING HUMANMILK AND BREASTFEEDING

1 The use of human milk is recom-mended for its numerous healthbenefits including reducing therisk of SUID

2 Special care should be takenwhen mothers are rooming-inand breastfeeding to minimizethe risk of falling asleep with theinfant in the adult bed

3 Provide mothers with appropri-ate outpatient support to

optimize breastfeeding successafter discharge from the hospital

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

Consistent messaging and modelingin the newborn nursery have beenshown to improve parental intent tokeep infants supine and not sharesleep surfaces11242ndash244 In the NICUenvironment McMullin et al foundthat a bundled intervention fornursing can lead to consistentmodeling of safe sleep beforehospital discharge The interventionincluded nursing education cribcards written instructions reviewedwith parents and sleep sacks formodeling to parents Audits 6months after the intervention found98 of infants supine in open cribs93 of infants in sleep sacks and88 of bassinets with safe sleepcrib cards visible245

Standardized programs have alsodemonstrated higher rates of supinesleep and other safe sleep behaviorsin the home246247 Given that 20of SUID cases involve preterminfants and preterm infants are at atwofold to threefold increased riskof SUID248ndash250 it is critical thatfamilies of infants in the NICU beexposed to safe sleep environmentalmodeling and education for asuccessful transition to a safe sleepenvironment in the home The AAPthrough its Committee on Fetus andNewborn recommends thatldquopreterm infants should be placedsupine for sleeping just as terminfants should and the parents ofpreterm infants should be counseledabout the importance of supinesleeping in preventing SUIDHospitalized preterm infants shouldbe kept predominantly in the supineposition at least from thepostmenstrual age of 32 weeksonward so that they becomeacclimated to supine sleeping beforedischargerdquo3


However as outlined in thisdocument not all infants will beclinically ready to be maintained ina safe sleep environment by 32weeksrsquo PMA Algorithms thataccount for some of the variablesdiscussed in this report have beendeveloped on the basis of literaturereview expert opinions and unitconsensus14251 Qualityimprovement programs using thesealgorithms can result in both moreconsistent modeling in the NICU andimproved parental compliance withsafe sleep practices Hwang et al251

showed a pre- to postinterventionimprovement with overall safe sleepenvironmental compliance in 2community NICUs from 259 to797 (P lt 001) In another studyNICU compliance with supinepositioning increased from 39 to83 (P lt 001) provision of a firmsleeping surface increased from 5 to96 (P 5 001) and the removal ofsoft objects from the bed improvedfrom 45 to 75 (P 5 001)Furthermore parental compliancewith safe sleep practices in the daysafter discharge from the NICUimproved from 23 to 82(P lt 001) The largest improvementsinvolved placing infants supine forsleep (93 vs 73) dressing infantsappropriately (93 vs 66) andremoving extra soft blankets from thecrib (97 vs 61)14

Although many of the studiesshowing improvement in modelingsafe sleep have been single-centerstudies a recent evaluation byHwang et al252 of a statewidequality improvement projectincluding 10 level III NICUs inMassachusetts not only confirmedthe utility of an integrated approachto safe sleep in the NICU but alsodemonstrated that it can beamplified across institutions at thestate level via perinatal qualitycollaboratives Over a 2-year period7261 cribs were audited forcompliance with safe sleep which

was defined by 4 parameterssupine positioning a flat crib withno incline no positioning devicesand no toys comforters or fluffyblankets Compliance increased from48 at the start of the project to76 at 1 year and 81 by 2 yearsThree of the individual componentshad compliance greater than 90 atthe end of the study

Many states have been focusingefforts on hospital-basedinterventions to promote safe sleepbehaviors anticipating that thedownstream effect will be adecrease in SUID and infant sleep-related deaths Some studies andepidemiological data support thistactic In Tennessee Heitmann et alanalyzed a Department of Healthprogram to implement a safe sleeppolicy at all 71 birthing hospitals inthe state Audits revealed a 456decrease in infants found with anyrisk factors for unsafe sleep Therewere significant decreases in infantsfound asleep nonsupine with a toyor object in the crib and notsleeping in a crib253

Creating a culture of infant sleepsafety in the NICU setting can bechallenging At the institutional leveldiffusion of innovation theory canhelp guide culture change Successfulquality improvement efforts require ateam of key players including (1)opinion leaders the respected leaderswho have influence over others (2)change agents the key people whosupport change stabilize adoptionand solve problems and (3) changeaides trustworthy people on the frontlines who help maintain change

In addition people responddifferently to change so it isimportant to seek out the innovatorsor risk takers who like new thingsand the early adopters who acceptchange readily It is equallyimportant that change agents andaides work closely with the latemajority or skeptics and the

traditionalists who prefer the statusquo Resistance to change iscommon so consensus building isessential to success Ideally thecomponents of change should bedeveloped by a multidisciplinaryteam to reflect input fromphysicians nursing lactationconsultants respiratory therapistsand development therapists(physical therapists occupationaltherapists and speech therapists)Having access to local state andnational statistics regarding SUIDcan facilitate breakdown of barriersto promoting consistent safe sleepeducation and modeling Statisticscan be obtained through multiplesources including state departmentsof health the Centers for DiseaseControl and Prevention throughCDC Wonder linked birth and infantdeath records (httpswondercdcgovlbdhtml) and yearly state childdeath review reports In additionhospitals can work together with lo-cal coroners medical examiners andchild death review teams to providefeedback on the effectiveness ofsafety efforts One study demon-strated the efficacy of a sustainedquality improvement effort thatlinked outcome data from local childfatality review teams The averagedeath rate decreased from 108 in-fants per 1000 births preinterven-tion to 048 infants per 1000 birthsafter complete intervention withfeedback from child fatality reviewteams and performance improve-ment methodology254 The authorsconcluded that repeated messagingand education by the entire nurserystaff has the potential to play a rolein reducing sleep-related deaths ininfants born at a hospital

CONCLUSIONS

As clinicians we must find equipoisebetween the acute physiologic needsof the infant and the inevitablenecessity to provide a home safesleep environment before dischargefrom the hospital There are many


competing and conflicting needs forthe NICU patient and familyPreterm infants are at increased riskof SUID so as providers we shouldfocus on sharing regular repetitiveand consistent education withfamilies throughout thehospitalization Through ourmessaging with not only our wordsbut also our modeling behaviors wewill enable NICU families to beproperly prepared for the transitionhome to a safe sleep environment

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

COMMITTEE ON FETUS AND NEWBORN2019ndash2020James 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 ndash AmericanAcademy of Pediatrics Section on SurgeryMichael Narvey MD ndash Canadian Paediatric

SocietyRussell Miller MD ndash American College ofObstetricians and GynecologistsRADM Wanda Barfield MD MPH FAAP ndashCenters for Disease Control and PreventionLisa Grisham APRN NNP-BC ndash 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 FAAPMichael H Goodstein MD FAAPFern R Hauck MD MS

CONSULTANTSElizabeth Bundock MD PhD ndash NationalAssociation of Medical Examiners

Lorena Kaplan MPH ndash Eunice KennedyShriver National Institute for Child Healthand Human Development

Sharyn Parks Brown PhD MPH ndash Centersfor Disease Control and Prevention

Marion Koso-Thomas MD MPH ndash EuniceKennedy Shriver National Institute for ChildHealth and Human Development

Carrie K Shapiro-Mendoza PhD MPH ndashCenters for Disease Control and Prevention

STAFFJames Couto MA

ABBREVIATIONS

AAP American Academy ofPediatrics

aOR adjusted odds ratioCI confidence intervalCPSC Consumer Product Safety

CommissionDDH developmental dysplasia of

the hipDP deformational plagiocephalyGER gastroesophageal refluxGERD gastroesophageal reflux

diseaseNICE National Institute for

Health and ClinicalExcellence

NOWS neonatal opioidwithdrawal syndrome

NSP nonsynostotic plagiocephalyPMA postmenstrual ageSIDS sudden infant death

syndromeSSC skin-to-skin careSUID sudden unexpected infant

death

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

DOI httpsdoiorg101542peds2021-052046

Address correspondence to Michael Goodstein MD FAAP E-mail mgoodsteinwellspanorg

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright 2021 by the American Academy of Pediatrics


FUNDING No external funding

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

REFERENCES

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environment Pediatrics2016138(5)e20162940

2 Moon RY Task Force on Sudden InfantDeath Syndrome SIDS and other sleep-related infant deaths updated 2016recommendations for a safe infant

sleeping environment Pediatrics2016138(5)e20162938

3 American Academy of Pediatrics Com-mittee on Fetus and Newborn Hospitaldischarge of the high-risk neonatePediatrics 2008122(5)1119ndash1126


4 Eichenwald EC Committee on Fetusand Newborn Diagnosis and manage-ment of gastroesophageal reflux inpreterm infants Pediatrics2018142(1)e20181061

5 Attarian S Tran LC Moore A StantonG Meyer E Moore RP The neurodeve-lopmental impact of neonatal mor-phine administration Brain Sci20144(2)321ndash334

6 Kocek M Wilcox R Crank C Patra KEvaluation of the relationship betweenopioid exposure in extremely low birthweight infants in the neonatal inten-sive care unit and neurodevelopmentaloutcome at 2 years Early Hum Dev20169229ndash32

7 Steinhorn R McPherson C AndersonPJ Neil J Doyle LW Inder T Neonatalmorphine exposure in very preterm in-fants-cerebral development and out-comes J Pediatr2015166(5)1200ndash1207e4

8 Malloy MH Hoffman HJ Prematuritysudden infant death syndrome andage of death Pediatrics 199596(3 Pt1)464ndash471

9 Aris C Stevens TP Lemura C et alNICU nursesrsquo knowledge and dischargeteaching related to infant sleep posi-tion and risk of SIDS Adv NeonatalCare 20066(5)281ndash294

10 Barsman SG Dowling DA Damato EGCzeck P Neonatal nursesrsquo beliefsknowledge and practices in relation tosudden infant death syndrome risk-re-duction recommendations Adv Neona-tal Care 201515(3)209ndash219

11 Srivatsa B Eden AN Mir MA Infantsleep position and SIDS a hospital-based interventional study J UrbanHealth 199976(3)314ndash321

12 Moon RY Oden RP Grady KC Back toSleep an educational intervention withwomen infants and children programclients Pediatrics 2004113(3 pt1)542ndash547

13 Rasinski KA Kuby A Bzdusek SA Silves-tri JM Weese-Mayer DE Effect of asudden infant death syndrome risk re-duction education program on riskfactor compliance and informationsources in primarily black urban com-munities Pediatrics 2003111(4 pt 1)Available at wwwpediatricsorgcgicontentfull1114e347

14 Gelfer P Cameron R Masters K Kenne-dy KA Integrating ldquoBack to Sleeprdquo rec-ommendations into neonatal ICUpractice Pediatrics 2013131(4) Avail-able at wwwpediatricsorgcgicontentfull1314e1264

15 Brydges CR Landes JK Reid CL Camp-bell C French N Anderson M Cognitiveoutcomes in children and adolescentsborn very preterm a meta-analysisDev Med Child Neurol201860(5)452ndash468

16 Vohr BR Neurodevelopmental out-comes of extremely preterm infantsClin Perinatol 201441(1)241ndash255

17 Coughlin M Gibbins S Hoath S Coremeasures for developmentally support-ive care in neonatal intensive careunits theory precedence and practiceJ Adv Nurs 200965(10)2239ndash2248

18 Symington A Pinelli J Developmentalcare for promoting development andpreventing morbidity in preterm in-fants Cochrane Database Syst Rev2006(2)CD001814

19 Als H Individualized developmentalcare for preterm infants 2017 Avail-able at wwwchild-encyclopediacomsitesdefaultfilestextes-expertsen809individualized-developmental-care-for-preterm-infantspdf AccessedDecember 10 2018

20 Johnston C Campbell-Yeo M Disher Tet al Skin-to-skin care for proceduralpain in neonates Cochrane DatabaseSyst Rev 2017(2)CD008435

21 Conde-Agudelo A Belizan JM Diaz-Ros-sello J Kangaroo mother care to re-duce morbidity and mortality in lowbirthweight infants Cochrane Data-base Syst Rev 2011(3)CD002771

22 Baley J Committee on Fetus and New-born Skin-to-skin care for term andpreterm infants in the neonatal ICUPediatrics 2015136(3)596ndash599

23 Shah PS Herbozo C Aliwalas LL ShahVS Breastfeeding or breast milk forprocedural pain in neonates CochraneDatabase Syst Rev 2012(12)CD004950

24 Laffin M Position Paper NICU Develop-mental Care Lonedell MO NationalPerinatal Association 2008

25 Kenner C McGrath J eds Developmen-tal Care of Newborns and Infants 2nd

ed Chicago IL National Association ofNeonatal Nurses 2015

26 Altimier L Kenner C Damus K TheWee Care Neuroprotective NICU Pro-gram (Wee Care) the effect of a com-prehensive developmental caretraining program on seven neuropro-tective core measures for family-cen-tered developmental care ofpremature neonates Newborn InfantNurs Rev 2015156ndash16

27 Milette I Martel MJ Ribeiro da SilvaM Coughlin McNeil M Guidelines forthe institutional implementation of de-velopmental neuroprotective care inthe neonatal intensive care unit PartA background and rationale A jointposition statement from the CANNCAPWHN NANN and COINN Can J NursRes 201749(2)46ndash62

28 National Association of NeonatalNurses Age-Appropriate Care of thePremature and Critically Ill Hospital-ized Infant Guideline for Practice Glen-view IL National Association ofNeonatal Nurses 2011

29 Waitzman K The importance of posi-tioning the near-term infant for sleepplay and development Newborn InfantNurs Rev 20077(2)76ndash81

30 Madlinger-Lewis L Reynolds L ZaremC Crapnell T Inder T Pineda R The ef-fects of alternative positioning on pre-term infants in the neonatal intensivecare unit a randomized clinical trialRes Dev Disabil 201435(2)490ndash497

31 Drake E Positioning the Neonate forBest Outcomes Monograph GlenviewIL National Association of NeonatalNurses 2017

32 Lockridge T Podruchny A Thorngate IDevelopmental Care CNE LearningModule Series Infant Sleep ProtocolsGlenview IL National Association ofNeonatal Nurses 2018

33 Hunter J Developmental Care CNELearning Module Series TherapeuticPositioning Neuromotor Physiologicand Sleep Implications Glenview ILNational Association of NeonatalNurses 2018

34 Zarem C Crapnell T Tiltges L et alNeonatal nursesrsquo and therapistsrsquo per-ceptions of positioning for preterm in-fants in the neonatal intensive care


unit Neonatal Netw201332(2)110ndash116

35 Coughlin M Lohman MB Gibbins S Re-liability and effectiveness of an infantpositioning assessment tool to stan-dardize developmentally supportive po-sitioning practices in the neonatalintensive care unit Newborn InfantNurs Rev 201010(2)104ndash106

36 Koninklijke Philips NV Therapeutic Po-sitioning in the NICU Amsterdam Neth-erlands Koninklijke Philips NV 2014

37 Spilker A Hill C Rosenblum R The ef-fectiveness of a standardised position-ing tool and bedside education on thedevelopmental positioning proficiencyof NICU nurses Intensive Crit CareNurs 20163510ndash15

38 Jeanson E One-on-one bedside nurseeducation as a means to improve posi-tioning consistency Newborn InfantNurs Rev 201313(1)27ndash30

39 Naugler MR DiCarlo K Barriers toand interventions that increasenursesrsquo and parentsrsquo compliancewith safe sleep recommendationsfor preterm infants Nurs WomensHealth 201822(1)24ndash39

40 Patton C Stiltner D Wright KBKautz DD Do nurses provide a safesleep environment for infants in thehospital setting An integrative re-view Adv Neonatal Care 201515(1)8ndash22

41 McMullen SL Transitioning prematureinfants supine state of the scienceMCN Am J Matern Child Nurs201338(1)8ndash12 quiz 13ndash14

42 Grazel R Phalen AG Polomano RC Im-plementation of the American Academyof Pediatrics recommendations to re-duce sudden infant death syndromerisk in neonatal intensive care unitsAn evaluation of nursing knowledgeand practice Adv Neonatal Care201010(6)332ndash342

43 Voos KC Terreros A Larimore P Leick-Rude MK Park N Implementing safesleep practices in a neonatal intensivecare unit J Matern Fetal NeonatalMed 201528(14)1637ndash1640

44 Kuhlmann S Ahlers-Schmidt CR Luka-siewicz G Truong TM Interventions toimprove safe sleep among hospitalizedinfants at eight childrenrsquos hospitalsHosp Pediatr 20166(2)88ndash94

45 Graven SN Early neurosensory visualdevelopment of the fetus and newbornClin Perinatol 200431(2)199ndash216 v

46 Gray L Philbin MK Effects of the neo-natal intensive care unit on auditoryattention and distraction Clin Perina-tol 200431(2)243ndash260 vi

47 Wachman EM Lahav A The effects ofnoise on preterm infants in the NICUArch Dis Child Fetal Neonatal Ed201196(4)F305ndashF309

48 Laudert S Liu WF Blackington S et alNICQ 2005 Physical Environment Ex-ploratory Group Implementing poten-tially better practices to support theneurodevelopment of infants in theNICU J Perinatol 200727(suppl2)S75ndashS93

49 van Sleuwen BE Engelberts AC Boere-Boonekamp MM Kuis W Schulpen TWLrsquoHoir MP Swaddling a systematic re-view Pediatrics 2007120(4) Availableat wwwpediatricsorgcgicontentfull1204e1097

50 van Sleuwen BE Lrsquohoir MP EngelbertsAC et al Comparison of behavior mod-ification with and without swaddlingas interventions for excessive crying JPediatr 2006149(4)512ndash517

51 Gerard CM Harris KA Thach BT Sponta-neous arousals in supine infants whileswaddled and unswaddled during rapideye movement and quiet sleep Pediat-rics 2002110(6) Available at wwwpediatricsorgcgicontentfull1106e70

52 Richardson HL Walker AM Horne RSMinimizing the risks of sudden infantdeath syndrome to swaddle or not toswaddle J Pediatr2009155(4)475ndash481

53 Nelson AM Risks and benefits of swad-dling healthy infants an integrative re-view MCN Am J Matern Child Nurs201742(4)216ndash225

54 Pease AS Fleming PJ Hauck FR et alSwaddling and the risk of sudden in-fant death syndrome a meta-analysisPediatrics 2016137(6)e20153275

55 McDonnell E Moon RY Infant deathsand injuries associated with wearableblankets swaddle wraps and swad-dling J Pediatr 2014164(5)1152ndash1156

56 Ponsonby A-L Dwyer T Gibbons LE Co-chrane JA Wang Y-G Factors potentiat-ing the risk of sudden infant death

syndrome associated with the proneposition N Engl J Med1993329(6)377ndash382

57 Nyqvist KH Anderson GC Bergman Net al Towards universal kangaroomother care recommendations andreport from the first European confer-ence and seventh international work-shop on kangaroo mother care ActaPaediatr 201099(6)820ndash826

58 Rey SE Martinez GH Maejo Racionaldel Nino Prematuro Conference 1 Cur-so de Medicina Fetal y Neonatal Bogo-ta Colombia Vundacion Vivar 1981

59 Cleveland L Hill CM Pulse WS DiCioc-cio HC Field T White-Traut R Systemat-ic review of skin-to-skin care for full-term healthy newborns J Obstet Gyne-col Neonatal Nurs 201746(6)857ndash869

60 Head LM The effect of kangaroo careon neurodevelopmental outcomes inpreterm infants J Perinat NeonatalNurs 201428(4)290ndash299 quiz E3ndashE4

61 Bastani F Rajai N Farsi Z Als H The ef-fects of kangaroo care on the sleepand wake states of preterm infants JNurs Res 201725(3)231ndash239

62 Feldman-Winter L Goldsmith JP Com-mittee on Fetus and Newborn TaskForce on Sudden Infant Death Syn-drome Safe sleep and skin-to-skincare in the neonatal period for healthyterm newborns Pediatrics2016138(3)e20161889

63 Graham JM Jr Kreutzman J Earl DHalberg A Samayoa C Guo X Deforma-tional brachycephaly in supine-sleepinginfants J Pediatr 2005146(2)253ndash257

64 Hummel P Fortado D Impacting infanthead shapes Adv Neonatal Care20055(6)329ndash340

65 Chang YJ Anderson GC Lin CH Effectsof prone and supine positions on sleepstate and stress responses in mechan-ically ventilated preterm infants duringthe first postnatal week J Adv Nurs200240(2)161ndash169

66 Chang YJ Anderson GC Dowling D LinCH Decreased activity and oxygen de-saturation in prone ventilated preterminfants during the first postnatalweek Heart Lung 200231(1)34ndash42

67 Maynard V Bignall S Kitchen S Ef-fect of positioning on respiratorysynchrony in non-ventilated pre-term


infants Physiother Res Int20005(2)96ndash110

68 American Academy of Pediatrics AAPTask Force on Infant Positioning andSIDS Positioning and SIDS [publishedcorrection appears in Pediatrics199290(2 pt 1)264] Pediatrics199289(6 pt 1)1120ndash1126

69 Cavalier A Picot MC Artiaga C et alPrevention of deformational plagioce-phaly in neonates Early Hum Dev201187(8)537ndash543

70 Hutchison BL Hutchison LA ThompsonJM Mitchell EA Plagiocephaly andbrachycephaly in the first two years oflife a prospective cohort study Pediat-rics 2004114(4)970ndash980

71 Kluba S Lypke J Kraut W Krimmel MHaas-Lude K Reinert S Preclinicalpathways to treatment in infants withpositional cranial deformity Int J OralMaxillofac Surg 201443(10)1171ndash1175

72 Mawji A Vollman AR Hatfield J McNeilDA Sauve R The incidence of position-al plagiocephaly a cohort study Pedi-atrics 2013132(2)298ndash304

73 Ohman A Nilsson S Lagerkvist ALBeckung E Are infants with torticollisat risk of a delay in early motor mile-stones compared with a control groupof healthy infants Dev Med Child Neu-rol 200951(7)545ndash550

74 Stellwagen L Hubbard E Chambers CJones KL Torticollis facial asymmetryand plagiocephaly in normal new-borns Arch Dis Child200893(10)827ndash831

75 de Chalain TM Park S Torticollis asso-ciated with positional plagiocephaly agrowing epidemic J Craniofac Surg200516(3)411ndash418

76 Rogers GF Deformational plagioce-phaly brachycephaly and scaphoce-phaly Part I terminology diagnosisand etiopathogenesis J CraniofacSurg 201122(1)9ndash16

77 Aarnivala H Vuollo V Harila V Heikki-nen T Pirttiniemi P Valkama AM Pre-venting deformational plagiocephalythrough parent guidance a random-ized controlled trial Eur J Pediatr2015174(9)1197ndash1208

78 Klimo P Jr Lingo PR Baird LC et alCongress of Neurological Surgeonssystematic review and evidence-based

guideline on the management of pa-tients with positional plagiocephalythe role of repositioning Neurosur-gery 201679(5)E627ndashE629

79 Tamber MS Nikas D Beier A et alCongress of Neurological Surgeonssystematic review and evidence-basedguideline on the role of cranial mold-ing orthosis (helmet) therapy for pa-tients with positional plagiocephalyNeurosurgery 201679(5)E632ndashE33

80 Lennartsson F Nordin P WennergrenG Teaching parents how to prevent ac-quired cranial asymmetry in infants JPediatr Nurs 201631(4)e252ndashe261

81 Sargent B Kaplan SL Coulter C BakerC Congenital muscular torticollisbridging the gap between researchand clinical practice Pediatrics2019144(2)e20190582

82 Mazzola C Baird LC Bauer DF et alCongress of Neurological Surgeonssystematic review and evidence-basedguideline for the diagnosis of patientswith positional plagiocephaly the roleof imaging Neurosurgery201679(5)E625ndashE626

83 Flannery AM Tamber MS Mazzola C etal Congress of Neurological Surgeonssystematic review and evidence-basedguidelines for the management of pa-tients with positional plagiocephaly ex-ecutive summary Neurosurgery201679(5)623ndash624

84 Baird LC Klimo P Jr Flannery AM etal Congress of Neurological Surgeonssystematic review and evidence-basedguideline for the management of pa-tients with positional plagiocephalythe role of physical therapy Neurosur-gery 201679(5)E630ndashE631

85 Shaw BA Segal LS Section on Ortho-paedics Evaluation and referral for de-velopmental dysplasia of the hip ininfants Pediatrics2016138(6)e20163107

86 Bache CE Clegg J Herron M Risk fac-tors for developmental dysplasia ofthe hip ultrasonographic findings inthe neonatal period J Pediatr OrthopB 200211(3)212ndash218

87 Imrie M Scott V Stearns P Bastrom TMubarak SJ Is ultrasound screeningfor DDH in babies born breech suffi-cient J Child Orthop 20104(1)3ndash8

88 Suzuki S Yamamuro T Avascular ne-crosis in patients treated with the Pav-lik harness for congenital dislocationof the hip J Bone Joint Surg Am199072(7)1048ndash1055

89 Barr LV Rehm A Should all twins andmultiple births undergo ultrasound ex-amination for developmental dysplasiaof the hip A retrospective study of990 multiple births Bone Joint J201395-B(1)132ndash134

90 Mulpuri K Song KM Gross RH et alThe American Academy of OrthopaedicSurgeons evidence-based guideline ondetection and nonoperative manage-ment of pediatric developmental dys-plasia of the hip in infants up to sixmonths of age J Bone Joint Surg Am201597(20)1717ndash1718

91 Murnaghan ML Browne RH Sucato DJBirch J Femoral nerve palsy in Pavlikharness treatment for developmentaldysplasia of the hip J Bone Joint SurgAm 201193(5)493ndash499

92 Rombouts JJ Kaelin A Inferior (obtu-rator) dislocation of the hip in neo-nates A complication of treatment bythe Pavlik harness J Bone Joint SurgBr 199274(5)708ndash710

93 Mubarak S Garfin S Vance R McKin-non B Sutherland D Pitfalls in the useof the Pavlik harness for treatment ofcongenital dysplasia subluxation anddislocation of the hip J Bone JointSurg Am 198163(8)1239ndash1248

94 Kitoh H Kawasumi M Ishiguro N Pre-dictive factors for unsuccessful treat-ment of developmental dysplasia ofthe hip by the Pavlik harness J Pe-diatr Orthop 200929(6)552ndash557

95 Committee on Quality ImprovementSubcommittee on Developmental Dys-plasia of the Hip American Academyof Pediatrics Clinical practice guide-line early detection of developmentaldysplasia of the hip Pediatrics2000105(4 pt 1)896ndash905

96 Karp HN Safe swaddling and healthyhips donrsquot toss the baby out with thebathwater Pediatrics2008121(5)1075ndash1076

97 Gerard CM Harris KA Thach BT Physi-ologic studies on swaddling an an-cient child care practice which maypromote the supine position for infantsleep J Pediatr 2002141(3)398ndash403


98 Kanetake J Aoki Y Funayama M Evalu-ation of rebreathing potential on bed-ding for infant use Pediatr Int200345(3)284ndash289

99 Kemp JS Thach BT Quantifying the po-tential of infant bedding to limit CO2dispersal and factors affecting re-breathing in bedding J Appl Physiol(1985) 199578(2)740ndash745

100 Kemp JS Livne M White DK Arfken CLSoftness and potential to cause re-breathing Differences in bedding usedby infants at high and low risk forsudden infant death syndrome J Pe-diatr 1998132(2)234ndash239

101 Patel AL Harris K Thach BT InspiredCO(2) and O(2) in sleeping infants re-breathing from bedding relevance forsudden infant death syndrome J ApplPhysiol (1985) 200191(6)2537ndash2545

102 Tuffnell CS Petersen SA Wailoo MPProne sleeping infants have a reducedability to lose heat Early Hum Dev199543(2)109ndash116

103 Ammari A Schulze KF Ohira-Kist K etal Effects of body position on thermalcardiorespiratory and metabolic activi-ty in low birth weight infants EarlyHum Dev 200985(8)497ndash501

104 Fyfe KL Yiallourou SR Wong FY Odoi AWalker AM Horne RS Cerebral oxygen-ation in preterm infants Pediatrics2014134(3)435ndash445

105 Horne RSC Fung ACH NcNeil S FyfeKL Odoi A Wong FY The longitudinaleffects of persistent apnea on cere-bral oxygenation in infants born pre-term J Pediatr 201718279ndash84

106 Wong FY Witcombe NB Yiallourou SR etal Cerebral oxygenation is depressedduring sleep in healthy term infantswhen they sleep prone Pediatrics2011127(3) Available at wwwpediatricsorgcgicontentfull1273e558

107 Peng NH Chen LL Li TC Smith MChang YS Huang LC The effect of posi-tioning on preterm infantsrsquo sleep-wakestates and stress behaviours duringexposure to environmental stressorsJ Child Health Care201418(4)314ndash325

108 Picheansathian W Woragidpoonpol PBaosoung C Positioning of preterm in-fants for optimal physiological devel-opment a systematic review JBILibrary Syst Rev 20097(7)224ndash259

109 Wagaman MJ Shutack JG MoomjianAS Schwartz JG Shaffer TH Fox WWImproved oxygenation and lung com-pliance with prone positioning of neo-nates J Pediatr 197994(5)787ndash791

110 Albert RK Hubmayr RD The prone po-sition eliminates compression of thelungs by the heart Am J Respir CritCare Med 2000161(5)1660ndash1665

111 Kassim Z Donaldson N Khetriwal B etal Sleeping position oxygen saturationand lung volume in convalescent pre-maturely born infants Arch Dis ChildFetal Neonatal Ed200792(5)F347ndashF350

112 Wolfson MR Greenspan JS Deoras KSAllen JL Shaffer TH Effect of positionon the mechanical interaction betweenthe rib cage and abdomen in preterminfants J Appl Physiol (1985)199272(3)1032ndash1038

113 Gillies D Wells D Bhandari AP Posi-tioning for acute respiratory distressin hospitalised infants and childrenCochrane Database Syst Rev2012(7)CD003645

114 Bhat RY Leipeuroaleuroa JA Singh NR RaffertyGF Hannam S Greenough A Effect ofposture on oxygenation lung volumeand respiratory mechanics in prema-ture infants studied before dischargePediatrics 2003112(1 pt 1)29ndash32

115 Levy J Habib RH Liptsen E et alProne versus supine positioning in thewell preterm infant effects on workof breathing and breathing patternsPediatr Pulmonol 200641(8)754ndash758

116 Hutchison AA Ross KR Russell G Theeffect of posture on ventilation andlung mechanics in preterm and light-for-date infants Pediatrics197964(4)429ndash432

117 Elder DE Campbell AJ Galletly D Effectof position on oxygen saturation andrequirement in convalescent preterminfants Acta Paediatr2011100(5)661ndash665

118 Leipeuroaleuroa JA Bhat RY Rafferty GF Han-nam S Greenough A Effect of pos-ture on respiratory function anddrive in preterm infants prior to dis-charge Pediatr Pulmonol200336(4)295ndash300

119 Poets CF von Bodman A Placing pre-term infants for sleep first prone

then supine Arch Dis Child Fetal Neo-natal Ed 200792(5)F331ndashF332

120 Insalaco LF Scott AR Peripartum Man-agement of Neonatal Pierre Robin Se-quence Clin Perinatol201845(4)717ndash735

121 Committee on Fetus and NewbornAmerican Academy of Pediatrics Ap-nea sudden infant death syndromeand home monitoring Pediatrics2003111(4 pt 1)914ndash917

122 Henderson-Smart DJ The effect of ges-tational age on the incidence and du-ration of recurrent apnoea innewborn babies Aust Paediatr J198117(4)273ndash276

123 Darnall RA Chen X Nemani KV et alEarly postnatal exposure to intermit-tent hypoxia in rodents is proinflam-matory impairs white matter integrityand alters brain metabolism PediatrRes 201782(1)164ndash172

124 Janvier A Khairy M Kokkotis A Corm-ier C Messmer D Barrington KJ Ap-nea is associated withneurodevelopmental impairment invery low birth weight infants J Perina-tol 200424(12)763ndash768

125 Pillekamp F Hermann C Keller T vonGontard A Kribs A Roth B Factorsinfluencing apnea and bradycardia ofprematurity - implications for neuro-development Neonatology200791(3)155ndash161

126 Kurlak LO Ruggins NR Stephenson TJEffect of nursing position on incidencetype and duration of clinically signifi-cant apnoea in preterm infants ArchDis Child Fetal Neonatal Ed199471(1)F16ndashF19

127 Heimler R Langlois J Hodel DJ NelinLD Sasidharan P Effect of positioningon the breathing pattern of preterminfants Arch Dis Child199267(3)312ndash314

128 Keene DJ Wimmer JEJ Jr Mathew OPDoes supine positioning increase ap-nea bradycardia and desaturation inpreterm infants J Perinatol200020(1)17ndash20

129 Bhat RY Hannam S Pressler R Raff-erty GF Peacock JL Greenough A Ef-fect of prone and supine position onsleep apneas and arousal in preterminfants Pediatrics2006118(1)101ndash107


130 Ballout RA Foster JP Kahale LA BadrL Body positioning for spontaneouslybreathing preterm infants with ap-noea Cochrane Database Syst Rev2017(1)CD004951

131 Eichenwald EC Committee on Fetusand Newborn American Academy ofPediatrics Apnea of prematurity Pedi-atrics 2016137(1)e20153757

132 Omari TI Barnett CP Benninga MA etal Mechanisms of gastro-oesophagealreflux in preterm and term infantswith reflux disease Gut200251(4)475ndash479

133 Omari TI Barnett C Snel A et alMechanisms of gastroesophageal re-flux in healthy premature infants J Pe-diatr 1998133(5)650ndash654

134 Vandenplas Y Rudolph CD Di LorenzoC et al North American Society for Pe-diatric Gastroenterology Hepatologyand Nutrition European Society for Pe-diatric Gastroenterology Hepatologyand Nutrition Pediatric gastroesopha-geal reflux clinical practice guidelinesjoint recommendations of the NorthAmerican Society for Pediatric Gastro-enterology Hepatology and Nutrition(NASPGHAN) and the European Societyfor Pediatric Gastroenterology Hepatol-ogy and Nutrition (ESPGHAN) J PediatrGastroenterol Nutr 200949(4)498ndash547

135 Vandenplas Y Hassall E Mechanismsof gastroesophageal reflux and gastro-esophageal reflux disease J PediatrGastroenterol Nutr 200235(2)119ndash136

136 Peter CS Sprodowski N Bohnhorst BSilny J Poets CF Gastroesophageal re-flux and apnea of prematurity no tem-poral relationship Pediatrics2002109(1)8ndash11

137 Mendes TB Mezzacappa MA Toro AARibeiro JD Risk factors for gastro-esophageal reflux disease in very lowbirth weight infants with bronchopul-monary dysplasia J Pediatr (Rio J)200884(2)154ndash159

138 Schurr P Findlater CK Neonatal myth-busters evaluating the evidence forand against pharmacologic and non-pharmacologic management of gastro-esophageal reflux Neonatal Netw201231(4)229ndash241

139 Berseth C Motor function in the stom-ach and small intestine in the neo-nate NeoReviews 20067(1)e28ndashe33

140 Golski CA Rome ES Martin RJ et alPediatric specialistsrsquo beliefs about gas-troesophageal reflux disease in pre-mature infants Pediatrics2010125(1)96ndash104

141 Rosen R Vandenplas Y Singendonk Met al Pediatric gastroesophageal re-flux clinical practice guidelines Jointrecommendations of the North Ameri-can Society for Pediatric Gastroenter-ology Hepatology and Nutrition andthe European Society for PediatricGastroenterology Hepatology and Nu-trition J Pediatr Gastroenterol Nutr201866(3)516ndash554

142 Almeida MB Almeida JA Moreira MENovak FR Adequacy of human milk vis-cosity to respond to infants with dys-phagia experimental study J ApplOral Sci 201119(6)554ndash559

143 Beal J Silverman B Bellant J YoungTE Klontz K Late onset necrotizing en-terocolitis in infants following use of axanthan gum-containing thickeningagent J Pediatr 2012161(2)354ndash356

144 Salvatore S Vandenplas Y Gastro-esophageal reflux and cow milk aller-gy is there a link Pediatrics2002110(5)972ndash984

145 Martin RJ Di Fiore JM Hibbs AM Gas-troesophageal reflux in preterm in-fants is positioning the answer JPediatr 2007151(6)560ndash561

146 Bhat RY Rafferty GF Hannam S Gree-nough A Acid gastroesophageal refluxin convalescent preterm infants effectof posture and relationship to apneaPediatr Res 200762(5)620ndash623

147 Corvaglia L Rotatori R Ferlini M AcetiA Ancora G Faldella G The effect ofbody positioning on gastroesophagealreflux in premature infants evaluationby combined impedance and pH moni-toring J Pediatr2007151(6)591ndash596e1

148 van Wijk MP Benninga MA DavidsonGP Haslam R Omari TI Small volumesof feed can trigger transient loweresophageal sphincter relaxation andgastroesophageal reflux in the rightlateral position in infants J Pediatr2010156(5)744ndash748e1

149 Omari TI Rommel N Staunton E et alParadoxical impact of body positioningon gastroesophageal reflux and

gastric emptying in the premature ne-onate J Pediatr 2004145(2)194ndash200

150 van Wijk MP Benninga MA Dent J etal Effect of body position changes onpostprandial gastroesophageal refluxand gastric emptying in the healthypremature neonate J Pediatr2007151(6)585ndash590e2

151 Byard RW Beal SM Gastric aspirationand sleeping position in infancy andearly childhood J Paediatr ChildHealth 200036(4)403ndash405

152 Malloy MH Trends in postneonatal as-piration deaths and reclassification ofsudden infant death syndrome impactof the ldquoBack to Sleeprdquo program Pedi-atrics 2002109(4)661ndash665

153 Tablizo MA Jacinto P Parsley D ChenML Ramanathan R Keens TG Supinesleeping position does not cause clini-cal aspiration in neonates in hospitalnewborn nurseries Arch Pediatr Ado-lesc Med 2007161(5)507ndash510

154 Oden RP Joyner BL Ajao TI Moon RYFactors influencing African Americanmothersrsquo decisions about sleep posi-tion a qualitative study J Natl Med As-soc 2010102(10)870ndash872 875ndash880

155 Colson ER McCabe LK Fox K et alBarriers to following the back-to-sleeprecommendations insights from focusgroups with inner-city caregivers Am-bul Pediatr 20055(6)349ndash354

156 Mosley JM Daily Stokes S Ulmer A In-fant sleep position discerning knowl-edge from practice Am J HealthBehav 200731(6)573ndash582

157 Moon RY Omron R Determinants of in-fant sleep position in an urban popu-lation Clin Pediatr (Phila)200241(8)569ndash573

158 Moon RY Patel KM Shaefer SJ Suddeninfant death syndrome in child caresettings Pediatrics 2000106(2 pt1)295ndash300

159 Moon RY Weese-Mayer DE Silvestri JMNighttime child care inadequate sud-den infant death syndrome risk factorknowledge practice and policies Pedi-atrics 2003111(4 pt 1)795ndash799

160 Ottolini MC Davis BE Patel K SachsHC Gershon NB Moon RY Prone infantsleeping despite the ldquoBack to Sleeprdquocampaign Arch Pediatr Adolesc Med1999153(5)512ndash517


161 Willinger M Ko C-W Hoffman HJ Kess-ler RC Corwin MJ Factors associatedwith caregiversrsquo choice of infant sleepposition 1994-1998 the National InfantSleep Position Study JAMA2000283(16)2135ndash2142

162 Von Kohorn I Corwin MJ Rybin DVHeeren TC Lister G Colson ER Influ-ence of prior advice and beliefs ofmothers on infant sleep position ArchPediatr Adolesc Med2010164(4)363ndash369

163 Meyers WF Herbst JJ Effectiveness ofpositioning therapy for gastroesopha-geal reflux Pediatrics198269(6)768ndash772

164 Tobin JM McCloud P Cameron DJ Pos-ture and gastro-oesophageal reflux acase for left lateral positioning ArchDis Child 199776(3)254ndash258

165 Shuren JE Letter to ManufacturersConcerning Medical Claims About In-fant Sleep Positioners Devices CanCreate Risk of Suffocation Washing-ton DC US Food and Drug Administra-tion 2010

166 Peachman RR Fisher-Price Rock n Playsleeper should be recalled consumerreports says 2019 Available at httpswwwconsumerreportsorgrecallsfisher-price-rock-n-play-sleeper-should-be-recalled-consumer-reports-says Accessed April 20 2019

167 US Consumer Product Safety Commis-sion Safety standard for infant sleepproducts Fed Regist201984(218)60649ndash60963

168 Mannen EM Carroll J Bumpass DB etal Biomechanical Analysis of InclinedSleep Products Little Rock AR Univer-sity of Arkansas 2019

169 Batra EK Midgett JD Moon RY Haz-ards associated with sitting and carry-ing devices for children two years andyounger J Pediatr2015167(1)183ndash187

170 Sahni R Temperature control in new-born infants In Polin RA Rowitch DHBenitz WE Fox WW eds Fetal and Neo-natal Physiology Philadelphia PAElsevier 2017459ndash489

171 Bissinger RL Annibale DJ Thermoreg-ulation in very low-birth-weight infantsduring the golden hour results andimplications Adv Neonatal Care201010(5)230ndash238

172 Altimier L Thermoregulation whatrsquosnew Whatrsquos not Newborn Infant NursRev 201212(1)51ndash63

173 Blair PS Mitchell EA Heckstall-SmithEM Fleming PJ Head covering - a ma-jor modifiable risk factor for suddeninfant death syndrome a systematicreview Arch Dis Child200893(9)778ndash783

174 Elabbassi EB Chardon K Bach V Tell-iez F Delanaud S Libert JP Head insu-lation and heat loss in naked andclothed newborns using a thermalmannequin Med Phys200229(6)1090ndash1096

175 Roberts JR Use of a Stockinet Cap onPremature Infants After Delivery Den-ton TX Texas Womenrsquos University 1981

176 Trevisanuto D Doglioni N Cavallin FParotto M Micaglio M Zanardo V Heatloss prevention in very preterm in-fants in delivery rooms a prospectiverandomized controlled trial of polyeth-ylene caps J Pediatr2010156(6)914ndash917e1

177 Stothers JK Head insulation and heatloss in the newborn Arch Dis Child198156(7)530ndash534

178 Jefferies AL Canadian Paediatric Soci-ety Fetus and Newborn CommitteeGoing home facilitating discharge ofthe preterm infant Paediatr ChildHealth 201419(1)31ndash42

179 Schneiderman R Kirkby S Turenne WGreenspan J Incubator weaning inpreterm infants and associated prac-tice variation J Perinatol200929(8)570ndash574

180 Shankaran S Bell EF Laptook AR et alEunice Kennedy Shriver National Insti-tute of Child Health and Human Devel-opment Neonatal Research NetworkWeaning of moderately preterm in-fants from the incubator to the crib arandomized clinical trial J Pediatr201920496ndash102e4

181 Barone G Corsello M Papacci P PrioloF Romagnoli C Zecca E Feasibility oftransferring intensive cared preterminfants from incubator to open crib at1600 grams Ital J Pediatr 20144041

182 New K Flenady V Davies MW Transferof preterm infants from incubator toopen cot at lower versus higher bodyweight Cochrane Database Syst Rev2011(9)CD004214

183 Fleming PJ Gilbert R Azaz Y et al In-teraction between bedding and sleep-ing position in the sudden infantdeath syndrome a population basedcase-control study BMJ1990301(6743)85ndash89

184 Ponsonby A-L Dwyer T Gibbons LE Co-chrane JA Jones ME McCall MJ Ther-mal environment and sudden infantdeath syndrome case-control studyBMJ 1992304(6822)277ndash282

185 Mitchell EA Blair PS SIDS prevention3000 lives saved but we can do betterN Z Med J 2012125(1359)50ndash57

186 Moon RY Hauck FR Risk factors andtheories In Duncan JR Byard RW edsSIDS Sudden Infant and Early Child-hood Death The Past the Present andthe Future Adelaide Australia Univer-sity of Adelaide Press 2018

187 Wilson CA Taylor BJ Laing RM Wil-liams SM Mitchell EA Clothing andbedding and its relevance to suddeninfant death syndrome further resultsfrom the New Zealand Cot Death StudyJ Paediatr Child Health199430(6)506ndash512

188 Fulmer M Zachritz W Posencheg MAIntensive care neonates and evidenceto support the elimination of hats forsafe sleep Adv Neonatal Care202020(3)229ndash232

189 Maisels MJ McDonagh AF Photothera-py for neonatal jaundice N Engl JMed 2008358(9)920ndash928

190 Bhutani VK Johnson L Sivieri EM Pre-dictive ability of a predischarge hour-specific serum bilirubin for subse-quent significant hyperbilirubinemia inhealthy term and near-term newbornsPediatrics 1999103(1)6ndash14

191 Yamauchi Y Kasa N Yamanouchi I Is itnecessary to change the babiesrsquo posi-tion during phototherapy Early HumDev 198920(3ndash4)221ndash227

192 Lee Wan Fei S Abdullah KL Effect ofturning vs supine position under pho-totherapy on neonates with hyperbilir-ubinemia a systematic review J ClinNurs 201524(5ndash6)672ndash682

193 Donneborg ML Knudsen KB EbbesenF Effect of infantsrsquo position on serumbilirubin level during conventionalphototherapy Acta Paediatr201099(8)1131ndash1134


194 Bhethanabhotla S Thukral A SankarMJ Agarwal R Paul VK Deorari AK Ef-fect of position of infant during photo-therapy in management ofhyperbilirubinemia in late pretermand term neonates a randomized con-trolled trial J Perinatol201333(10)795ndash799

195 National Institute for Health and CareExcellence Jaundice in newborn ba-bies under 28 days 2010 Available athttpswwwniceorgukguidancecg98 Accessed December 10 2018

196 American Academy of Pediatrics Sub-committee on HyperbilirubinemiaManagement of hyperbilirubinemia inthe newborn infant 35 or more weeksof gestation Pediatrics2004114(1)297ndash316

197 Hudak ML Tan RC Committee onDrugs Committee on Fetus and New-born American Academy of PediatricsNeonatal drug withdrawal Pediatrics2012129(2) Available at wwwpediatricsorgcgicontentfull1292e540

198 Edwards L Brown LF Nonpharmaco-logic management of neonatal absti-nence syndrome an integrativereview Neonatal Netw201635(5)305ndash313

199 Ryan G Dooley J Gerber Finn L KellyL Nonpharmacological managementof neonatal abstinence syndrome areview of the literature J Matern FetalNeonatal Med 201932(10)1735ndash1740

200 Maguire D Care of the infant withneonatal abstinence syndromestrength of the evidence J PerinatNeonatal Nurs 201428(3)204ndash211quiz E3ndashE4

201 Wachman EM Schiff DM Silverstein MNeonatal abstinence syndrome advan-ces in diagnosis and treatment JAMA2018319(13)1362ndash1374

202 Grossman M Seashore C Holmes AVNeonatal abstinence syndrome man-agement a review of recent evidenceRev Recent Clin Trials201712(4)226ndash232

203 Walsh MC Crowley M Wexelblatt S etal Ohio Perinatal Quality CollaborativeOhio Perinatal Quality Collaborative im-proves care of neonatal narcotic absti-nence syndrome Pediatrics2018141(4)e20170900

204 Boundy EO Dastjerdi R Spiegelman Det al Kangaroo mother care and neo-natal outcomes a meta-analysis Pedi-atrics 2016137(1)e20152238

205 Welle-Strand GK Skurtveit S JanssonLM Bakstad B Bjarkoslash L Ravndal EBreastfeeding reduces the need forwithdrawal treatment in opioid-ex-posed infants Acta Paediatr2013102(11)1060ndash1066

206 Pace CA Kaminetzky LB Winter M etal Postpartum changes in methadonemaintenance dose J Subst AbuseTreat 201447(3)229ndash232

207 Cohen MC Morley SR Coombs RC Ma-ternal use of methadone and risk ofsudden neonatal death Acta Paediatr2015104(9)883ndash887

208 Blair PS Fleming PJ Smith IJ et alBabies sleeping with parents case-control study of factors influencingthe risk of the sudden infant deathsyndrome CESDI SUDI research groupBMJ 1999319(7223)1457ndash1461

209 Blair PS Sidebotham P Evason-Coombe C Edmonds M Heckstall-Smith EM Fleming P Hazardous co-sleeping environments and risk fac-tors amenable to change case-controlstudy of SIDS in south west EnglandBMJ 2009339b3666

210 Carpenter RG Irgens LM Blair PS etal Sudden unexplained infant death in20 regions in Europe case controlstudy Lancet 2004363(9404)185ndash191

211 Ohgi S Akiyama T Arisawa K Shige-mori K Randomised controlled trial ofswaddling versus massage in themanagement of excessive crying in in-fants with cerebral injuries Arch DisChild 200489(3)212ndash216

212 Byrne M Horowitz D Rocking as asoothing intervention the influence ofdirection and type of movement InfantBehav Dev 19814207ndash218

213 Pederson DR Soothing effect of rock-ing as determined by direction andfrequency of movement Can J BehavSci 19757(3)237ndash243

214 Meurooller EL de Vente W Rodenburg RInfant crying and the calming re-sponse parental versus mechanicalsoothing using swaddling sound andmovement PLoS One201914(4)e0214548

215 Maichuk GT Zahorodny W Marshall RUse of positioning to reduce the sever-ity of neonatal narcotic withdrawalsyndrome J Perinatol199919(7)510ndash513

216 Section on Breastfeeding Breastfeed-ing and the use of human milk Pediat-rics 2012129(3) Available at wwwpediatricsorgcgicontentfull1293e827

217 Herrmann K Carroll K An exclusivelyhuman milk diet reduces necrotizingenterocolitis Breastfeed Med20149(4)184ndash190

218 Assad M Elliott MJ Abraham JH De-creased cost and improved feedingtolerance in VLBW infants fed an exclu-sive human milk diet J Perinatol201636(3)216ndash220

219 Maffei D Schanler RJ Human milk isthe feeding strategy to prevent necro-tizing enterocolitis Semin Perinatol201741(1)36ndash40

220 Boyd CA Quigley MA Brocklehurst PDonor breast milk versus infant for-mula for preterm infants systematicreview and meta-analysis Arch DisChild Fetal Neonatal Ed200792(3)F169ndashF175

221 Ip S Chung M Raman G Trikalinos TALau J A summary of the Agency forHealthcare Research and Qualityrsquos evi-dence report on breastfeeding in de-veloped countries Breastfeed Med20094(suppl 1)S17ndashS30

222 Hauck FR Thompson JM Tanabe KOMoon RY Vennemann MM Breastfeed-ing and reduced risk of sudden infantdeath syndrome a meta-analysis Pedi-atrics 2011128(1)103ndash110

223 Vennemann MM Bajanowski T Brink-mann B et al GeSID Study GroupDoes breastfeeding reduce the risk ofsudden infant death syndrome Pediat-rics 2009123(3) Available at wwwpediatricsorgcgicontentfull1233e406

224 Thompson JMD Tanabe K Moon RY etal Duration of breastfeeding and riskof SIDS an individual participant datameta-analysis Pediatrics2017140(5)e20171324

225 Andreas NJ Kampmann B Mehring Le-Doare K Human breast milk a reviewon its composition and bioactivity Ear-ly Hum Dev 201591(11)629ndash635


226 Ballard O Morrow AL Human milkcomposition nutrients and bioactivefactors Pediatr Clin North Am201360(1)49ndash74

227 Fogerty AC Ford GL Willcox ME ClancySL Liver fatty acids and the sudden in-fant death syndrome Am J Clin Nutr198439(2)201ndash208

228 Xiang M Alfven G Blennow M TryggM Zetterstreuroom R Long-chain polyun-saturated fatty acids in human milkand brain growth during early infancyActa Paediatr 200089(2)142ndash147

229 Uauy R Hoffman DR Essential fat re-quirements of preterm infants Am JClin Nutr 200071(1 suppl)245Sndash250S

230 Kum-Nji P Mangrem CL Wells PJ Re-ducing the incidence of sudden infantdeath syndrome in the Delta region ofMississippi a three-pronged approachSouth Med J 200194(7)704ndash710

231 Kinney HC Brody BA Finkelstein DMVawter GF Mandell F Gilles FH Delayedcentral nervous system myelination inthe sudden infant death syndrome JNeuropathol Exp Neurol199150(1)29ndash48

232 Briere CE Lucas R McGrath JM Luss-ier M Brownell E Establishing breast-feeding with the late preterm infant inthe NICU J Obstet Gynecol NeonatalNurs 201544(1)102ndash113

233 Hallowell SG Spatz DL Hanlon AL Ro-gowski JA Lake ET Characteristics ofthe NICU work environment associatedwith breastfeeding support Adv Neo-natal Care 201414(4)290ndash300

234 Noble LM Okogbule-Wonodi AC YoungMA ABM clinical protocol 12 transi-tioning the breastfeeding preterm in-fant from the neonatal intensive careunit to home revised 2018 BreastfeedMed 201813(4)230ndash236

235 World Health Organization Infant andYoung Child Feeding Model Chapterfor Textbooks for Medical StudentsAnd Allied Health Professionals Gene-va Switzerland World Health Organiza-tion 2009

236 Heinrichs M Baumgartner T Kirsch-baum C Ehlert U Social support andoxytocin interact to suppress cortisoland subjective responses to psychoso-cial stress Biol Psychiatry200354(12)1389ndash1398

237 Bittle MD Knapp H Polomano RC Gior-dano NA Brown J Stringer M Mater-nal sleepiness and risk of infantdrops in the postpartum period JtComm J Qual Patient Saf201945(5)337ndash347

238 Rychnovsky J Hunter LP The relation-ship between sleep characteristicsand fatigue in healthy postpartumwomen Womens Health Issues200919(1)38ndash44

239 Insana SP Montgomery-Downs HESleep and sleepiness among first-timepostpartum parents a field- and labo-ratory-based multimethod assessmentDev Psychobiol 201355(4)361ndash372

240 Ronzio CR Huntley E Monaghan MPostpartum mothersrsquo napping and im-proved cognitive growth fostering ofinfants results from a pilot study Be-hav Sleep Med 201311(2)120ndash132

241 Thach BT Deaths and near deaths ofhealthy newborn infants while bedsharing on maternity wards J Perina-tol 201434(4)275ndash279

242 Stastny PF Ichinose TY Thayer SD Ol-son RJ Keens TG Infant sleep position-ing by nursery staff and mothers innewborn hospital nurseries Nurs Res200453(2)122ndash129

243 Mason B Ahlers-Schmidt CR SchunnC Improving safe sleep environmentsfor well newborns in the hospital set-ting Clin Pediatr (Phila)201352(10)969ndash975

244 Colson ER Bergman DM Shapiro ELeventhal JH Position for newbornsleep associations with parentsrsquo per-ceptions of their nursery experienceBirth 200128(4)249ndash253

245 McMullen SL Lipke B LeMura C Sud-den infant death syndrome prevention

a model program for NICUs NeonatalNetw 200928(1)7ndash12

246 Goodstein MH Bell T Krugman SD Im-proving infant sleep safety through acomprehensive hospital-based pro-gram Clin Pediatr (Phila)201554(3)212ndash221

247 Kellams A Parker MG Geller NL et alTodaysBaby quality improvement safesleep teaching and role modeling in8 US maternity units Pediatrics2017140(5)e20171816

248 Blair PS Platt MW Smith IJ FlemingPJ CESDI SUDI Research Group Sud-den infant death syndrome and sleep-ing position in pre-term and low birthweight infants an opportunity for tar-geted intervention Arch Dis Child200691(2)101ndash106

249 Oyen N Markestad T Skaerven R etal Combined effects of sleeping posi-tion and prenatal risk factors in sud-den infant death syndrome the NordicEpidemiological SIDS Study Pediatrics1997100(4)613ndash621

250 Malloy MH Prematurity and sudden in-fant death syndrome United States2005-2007 J Perinatol201333(6)470ndash475

251 Hwang SS OrsquoSullivan A Fitzgerald EMelvin P Gorman T Fiascone JM Im-plementation of safe sleep practicesin the neonatal intensive care unit JPerinatol 201535(10)862ndash866

252 Hwang SS Melvin P Diop H Settle MMourad J Gupta M Implementation ofsafe sleep practices in MassachusettsNICUs a state-wide QI collaborative JPerinatol 201838(5)593ndash599

253 Heitmann R Nilles EK Jeans A et alImproving safe sleep modeling in thehospital through policy implementa-tion Matern Child Health J201721(11)1995ndash2000

254 Krugman SD Cumpsty-Fowler CJ Ahospital-based initiative to reducepostdischarge sudden unexpected in-fant deaths Hosp Pediatr20188(8)443ndash449


originally published online June 21 2021 Pediatrics Michael H Goodstein Dan L Stewart Erin L Keels and Rachel Y MoonTransition to a Safe Home Sleep Environment for the NICU Patient

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021-052046httppediatricsaappublicationsorgcontentearly20210621peds2including high resolution figures can be found at

References

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by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2021has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it


medically stable and significantlybefore their anticipated dischargefrom the hospital In particular verypreterm infants should be keptpredominantly in the supineposition by 32 weeksrsquo postmenstrualage (PMA) so that they becomeacclimated to supine sleeping beforedischarge from the hospital1ndash3

There are many other factors thatdefine a safe sleep environment tominimize the risk of sudden infantdeath syndrome (SIDS) accidentalsuffocation and strangulation andundetermined sleep deaths(collectively known as suddenunexpected infant death [SUID]) asoutlined in the same 2016 policystatement

During NICU hospitalization infantsare routinely kept in anenvironment that is not consistentwith these recommendations fornumerous reasons on the basis ofboth treatment of underlyingpathophysiology as well as thenormal physiology of the preterminfant Pathologic conditionsresulting in short-term respiratorydistress (respiratory distresssyndrome and transient tachypneaof the newborn) or long-termrespiratory compromise(bronchopulmonary dysplasia andpulmonary hypoplasia) result in useof positioning inconsistent with safesleep messaging Other conditionsthat may be pathologic such asgastroesophageal reflux (GER) leadto the use of therapeuticinterventions such as side-lyingposition and elevation of the head ofthe bed maneuvers the literaturesuggests may be of questionablevalue4 To reduce the need fornarcotic and anxiolytic medicationswhich have been reported to haveadverse effects onneurodevelopment5ndash7 infants withneonatal opioid withdrawalsyndrome (NOWS) may bepositioned prone or swaddledfirmly Developmental care for the

optimal growth and maturation ofthe preterm infant can include theuse of nonsupine positioning softmattresses and positionersAlthough developmental care hasbeen shown to be beneficial to thelong-term neurodevelopmentaloutcomes of preterm infants manyof the tools involved in theconstantly monitored NICUenvironment are contraindicatedafter hospital discharge Transitionto a safe sleep environment as soonas medically possible well beforedischarge from the hospital isextremely important because inpreterm infants the adjusted oddsratio (aOR) for SIDS is 185 to 272and for suffocation is 186 to 259compared with term infants and thesleep environment greatly affectsthe risk of these sleep-relateddeaths18

Although the AAP through itsCommittee on Fetus and Newbornrecommended the transition to theuse of the supine position by 32weeksrsquo PMA3 in 2008 and thisrecommendation was supported bythe AAP Task Force on SuddenInfant Death Syndrome in 201112

there is long-term and ongoingnonadherence to thisrecommendation from NICUproviders3910 Research onresistance to this recommendationhas thus far been focused on onlyNICU nurses In a 2006 survey of252 NICU nurses 65 identifiedprone positioning as the bestgeneral sleep position for preterminfants followed by 12 whobelieved either prone or side-lyingposition was the best sleepposition9 In addition the nursessurveyed were inconsistentregarding how they determinedwhen a preterm infant is ready tosleep supine Answers includedclose to discharge (13) whenmaintaining their body temperaturein an open crib (25) PMA of 34 to36 weeks (15) PMA $37 weeks

(13) and when the infantrsquosrespiratory status was stable (6)Nursing beliefs and knowledgecontinue to be a barrier to a cultureof consistent safe sleep messaging A2016 survey of 96 NICU nursesfound that 53 strongly agreed thatrecommendations make a differencein preventing SIDS and only 20strongly agreed that parents wouldmodel nursesrsquo behaviors at home10

Various reasons are given to explainwhy nonsupine positioning andother common practices contrary toa safe sleep environment persisteven when infants are approachingdischarge from the NICU Howeverstudies find that when expectant ornew parents receive education oninfant sleep safety on a consistentbasis their knowledge increases andtheir safe sleep behaviors improveregardless of the setting (eg well-infant nursery NICU SpecialSupplemental Nutrition Program forWomen Infants and Children officecommunity health center)11ndash14 Thepurpose of this report is to addressthe many issues that result inconflict with safe sleep guidelineslooking at the validity of practicesbased on review of the evidenceregarding pathophysiology andnormal physiology of the vulnerableinfant The goal of this technicalreport is not to provide an all-encompassing review of theliterature for each issue but rather asummary of data for each issue andprovide suggestions to resolveconflicting practices By creating aconsistent approach to transitioningthe infant in the NICU to a safe sleepenvironment as soon as medicallypossible well before hospitaldischarge families can be exposedto modeling of safe sleep behaviorsthat could decrease the risk of SUIDin this vulnerable population Areasof concern include developmentalcare andor neurodevelopmentalissues positional plagiocephaly andor torticollis orthopedic issues

















Swaddling



Skin-to-Skin Care





















































































Home Monitors



































THERMOREGULATION


























































































CONCLUSIONS








STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References




























Swaddling



Skin-to-Skin Care





















































































Home Monitors



































THERMOREGULATION


























































































CONCLUSIONS








STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References























































































Home Monitors



































THERMOREGULATION


























































































CONCLUSIONS








STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References







































THERMOREGULATION


























































































CONCLUSIONS








STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References


































































































CONCLUSIONS








STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References


















STAFFJim Couto MA







STAFFJames Couto MA

ABBREVIATIONS










death









REFERENCES





















































































































































































































































































References



























































































































































































































































































References













Transition to a Safe Home Sleep Environment for the NICU ......2021/06/21 · a safe sleep...

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Transcript of Transition to a Safe Home Sleep Environment for the NICU ......2021/06/21 · a safe sleep...