Barb Himes, CD

October marks Infant Safe Sleep Awareness Month and Sudden Infant Death Syndrome (SIDS) Awareness Month and is an excellent time to call attention to a risk that is likely overlooked in infant safe sleep education.

In May 2022, the American Academy of Pediatricians (AAP) released a study (1) of safe sleep practices during infant second sleep among a 1,500 sample of White (65%), Black (12%), and Hispanic (17%) participants, nearly three-fourths of which were female (74%). Safe sleep criteria followed AAP infant safe sleep guidelines and were defined as supine position, sleep in a separate space, and a crib, bassinet, cradle, or playard. 

The study also looked at parental age, race, and ethnicity; first-time parents; homes with smoke exposure; and infants born at 37 weeks. 

The results were sobering. While 44% met all three safe sleep practices at onset, it dropped to 39% reporting having a second-sleep practice, and, of those, 28% met the three criteria at sleep onset, but only 9% met them at both the first and second-time points. 

As the study authors point out, although nighttime waking is common with infants, less attention appears to be paid to infant second-sleep practices. This matters because sleep-related infant mortality claims 3,500 lives of babies in the United States each year, including sudden infant death syndrome (SIDS), accidental suffocation and strangulation in bed (ASSB), and deaths from unknown causes. 

The advent of the public health campaign Back to Sleep (now known as Safe to Sleep®) in the 1990s resulted in a 50% drop in the mortality rate between 1994 and 1999 (2), but this rate has since stayed relatively level, and sleep-related Sudden Unexplained Infant Death (SUID) remains the leading cause of death for infants one month to one year of age. 

At the core of the Back to Sleep and the subsequent campaigns are the AAP infant sleep guidelines, last updated in 2022, which also specify that in addition to placing infants sleep alone on their backs, the mattress is flat, firm, and level with no bedding, pillows or other items. Infants should share a room with adults during the first six months, but their sleep space should be separate. 

It matters that caregivers and health care providers counsel them to consider that the risks associated with not using safe sleep practices do not diminish from onset sleep to second sleep and may even increase. The study reported that 18% of infants who used a separate space at sleep onset slept with another person after nighttime waking, which can increase the risk of overlay and ASSB. 

Understanding family situations, characteristics, and cultural practices also play a role in advancing infant-safe sleep practices. Every family is different, and coming to pre-conclusions about their perspectives on safe sleep can be misleading. The study indicated that parent characteristics, including being under 25, first-time parents, parents identifying as Black non-Hispanic or Hispanic ethnicity, parent education (four-year degree or higher), smoking, and infants born at less than 37 weeks were associated with second-sleep practices after nighttime waking. 

However, results also indicated that households with cigarette smoke exposure and babies born at less than 37 weeks had a lower prevalence of meeting all three safe sleep criteria at sleep onset, which is important because both are at higher risk of sleep-related death. 

The study authors conclude that the findings “highlight that many parents may benefit from discussion with their pediatrician specifically focused on the importance of continued safe sleep practices after nighttime waking.” 

They also conclude, and we agree, that families and their healthcare providers should discuss nighttime wakings and the need for safe sleep practices every time. This is a component of our Straight Talk for Infant Safe Sleep workshops for healthcare providers, including nurses, agency workers, doulas, hospital staff, and others, and in our Let’s Talk Community Chats with parents, extended family, and other caregivers. 

The first, second, and all-time sleep preparation call for infant-safe sleep practices. 

References: 

1. Bryan MA, Florence A, Gower AD, Evans YN, Moreno MA. Safe sleep behaviors and factors associated with infant second sleep practices. Pediatrics. 2022; https://doi.org/10.1542/peds.2021-053935 
2. https://safetosleep.nichd.nih.gov/activities/SIDS/progress