Chapter : Safe Sleep Practices

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Chapter : Safe Sleep Practices

Reference Points

  • Why Are Safe Sleep Practices Important?

  • What are Safe Sleep Practices?

  • What are Not Safe Sleep Practices?

  • Personal Beliefs and Practices

  • Agency Policy

  • Assessing Safety and Providing Education

  • Documentation

  • Other References

Effective Date: Draft

Last Updated: 10/12/12

Why are Safe

Sleep Practices


  • Sudden unexpected infant deaths (SUID) that occur during sleep, have increased in incidence, particularly since 2005, both nationally and locally, particularly those resulting from suffocation, oxygen deprivation, and entrapment.

  • Most of these causes of SUID are preventable.

  • The risk of all sleep-related SUID can be reduced by focusing on safe sleep environment.

  • The risk of sleep-related serous long-term injury, such as permanent brain damage, from oxygen deprivation, can also be reduced by focusing on safe sleep environment.


Why are Safe

Sleep Practices

  • Safe Sleep Practices are the consistent use of evidence-based practices for every episode of sleep for children age 12 months and younger to decrease risk of injury and death

  • ABC: Simply put, the only safe practice is for an infant to always sleep Alone, on his or her Back, in a Crib.

  • More specifically, Safe Sleep Practices, as recommended in 2011 by theAmerican Academy of Pediatrics, include:

  • Room-sharing without bed-sharing (also known as co-sleeping): decreases the risk of SIDS by as much as 50%. (Placement of the crib, portable crib, play yard or bassinet close to the parents’ bed allows close parental proximity to the infant and facilitates feeding, comforting, and monitoring the infant, while removing the possibility of suffocation, strangulation, and entrapment that might occur when the infant is sleeping in the adults’ bed.)

  • Placement wholly on the back to sleep for every sleep, from the earliest age, including pre-term infants, by every caregiver, until one year of ages. (The supine, or back, sleep position does not increase the risk of choking and aspiration, even in infants with gastro-esophageal reflux. Once an infant can roll from supine to prone and from prone to supine, the infant can be allowed to remain in the sleep position that he or she assumes.)

  • Use of a firm sleep surface, such as a firm crib or bassinet mattress, covered by a fitted sheet, or a portable crib/play yard that conforms to safety standards.

  • Keeping all soft objects and loose bedding out of the crib. Infant sleep clothing that is designed to keep the infant warm without the possible hazard of head-covering or entrapment can be used. If a blanket is used, it should be lightweight and tucked into the foot and sides of the mattress, up to the child’s nipple line.

  • Avoid overheating. In general, infants should have no more than one layer more of clothing than an adult would wear to comfortable. Evaluate signs of overheating, such as sweating or the infant’s chest feeling hot to touch.

  • No smoking in the infant’s environment.

  • The use of pacifiers. (It does not need to be forced, and does not need to be re-inserted once the infant falls asleep. For breast-feeding infants, introduce pacifiers after breastfeeding is firmly established, usually by 3 to 4 weeks of age.)


What Are Not Safe Sleep Practices

There are many practices, some of which are commonly used, which increase the risk of infant death or injury, and so, are not safe:

  • Bed-sharing, with adults, or an adult, or another child, or another infant: increases the risk of suffocation, strangulation, and entrapment. Studies have not demonstrated any bed-sharing situations that are protective against SIDS or suffocation. The risks substantially increase in bed-sharing situations in which:

  1. The infant is younger than 3 months

  2. The bed is shared with multiple persons.

  3. Bed-sharing is on a soft surface.

  4. Bed-sharing is on a surface with soft bedding, including pillows, heavy blankets, quilts, and comforters.

  5. Bed-sharing is with someone who:

    1. Is a current smoker or if the mother smoked during pregnancy;

    2. Is excessively tired;

    3. Has or is using medications or substances that could

    4. Is not a parent, including other children;

  • Placing an infant on the front, or side.

  • Elevating the head of the infant or sleep surface (might result in the infant sliding toward the foot of the crib into a position that might compromise respiration).

  • Use of cribs with broken or missing parts (including those that presumably have been fixed).

  • Used of mattresses that are not designed for the specific product, such that there are gaps between the mattress and the side of the crib, bassinet, or portable crib or play yard.

  • Use of soft objects, pillows, pillow-like toys, comforters, quilts, sheepskings, thick or loose mattress covers, stuffed dolls and animals, loose sheets or blankets, and fluffy blankets.

  • Use of crib bumpers (increases the potential for entrapment, suffocation, and strangulation, and there is no evidence that they prevent injury).

  • Use of beds, and portable bed rails (increases the risk of entrapment, strangulation, and suffocation).

  • Sleep areas with dangling cords, electric wires, and window-covering cords (present a strangulation risk).

  • Sitting devices, such as car safety seats, strollers, swings, infant carriers and infant slings. (If an infant falls asleep in a sitting device, he or she should be moved to a crib or other appropriate flat surface as soon as is practical. When infant slings are used for carrying, it is important to ensure that the infant’s head is up and above the fabric, the face is visible, and that the nose and mouth are clear of obstructions.)

  • The use of home cardio respiratory monitors as a strategy for reducing the risk of SIDS (there is no evidence that they reduce such risk)

  • Adults falling asleep with infants in arm-chairs and couches, sometimes while nursing (creates an extremely high risk of suffocation. Infants should not be fed on a couch or armchair when there is a high risk that the parent might fall asleep).

  • The use of pacifiers which hang around the infant’s neck, or are attached to infant clothing, or have toys attached to them (increase risk of strangulation and choking).

  • The use of devices marketed to make bed-sharing safe, or to decrease the risk of SIDS, including in-bed co-sleepers, wedges, positioners, special mattresses, and special sleep surfaces. (There is no evidence that these devices reduce the risk of SIDS or suffocation, or that they are safe.)


Personal Beliefs and Practices

The Department is aware that the public, and staff may engage in many personal practices in their own families and with their own infants, or in child care, which are contrary to the Safe Sleep Practices which are currently uniformly recommended by:

  • the American Academy of Pediatrics.

  • the U.S. Department of Health and Human Services

  • the California Department of Social Services.

  • The Santa Clara County Office of the Medical Examiner and Coroner.

  • The Santa Clara County Public Health Department.

  • First 5 Santa Clara County.

Personal beliefs in long-standing practices which are currently considered unsafe and reinforced by:

  • Intergenerational childrearing patterns

  • Cultural beliefs

  • Personal positive experiences of their use without incidence of injury to infants

  • Product advertising

  • Movies, television, and magazine media

Books and articles and academics supporting practices which are currently recognized as unsafe.


Agency Policy

While recognizing that staff may not personally adhere to some or all Safe Sleep Practices, DFCS, as an agency dedicated to the safety of children, and having responsibility for promoting behavior which reduces the incidence of death and injury to children in the community, expects staff to consistently and actively promote the use of Safe Sleep Practices by clients and caregivers of children within the responsibility of the Department.

The situations for assessing infant safety, and providing education, in regard To Safe Sleep Practices include:

  • Screening child abuse and neglect referrals concerning infants

  • Investigating referrals concerning infants

  • Dependency Investigation concerning infants

  • Placement of infants in out-of-home care

  • Provision of Voluntary and Court-Ordered Services to families with infants

  • Foster Home Recruitment and Pre-Licensure

  • Foster Parent Training

  • Foster Home Licensing

  • Assessment of Relatives and Non-Relative Extended Family Members (NREFM’s) for placement for infants

  • Assessment of Adoptive families

  • Services to Non-Minor Dependents

  • Services to Pregnant and Parenting Teens

  • Parent Education

  • Foster Home Resources and Supports


Assessing Safety and Providing Education

Social workers are to assess the safety of infants, and include Safe Sleep Practices in those assessments, in all situations in which social work staff interact with:

  • pregnant or expectant parents,

  • parents and guardians of infants,

  • and caregivers or potential caregivers of infants, including foster care providers, relatives, NREFM’s, and childcare providers.

This includes asking questions and having discussions about sleep Practices for naps and bedtimes.

During home visits, this includes observing sleep areas and sleep practices.
Social workers are to consider Safe Sleep Practices while considering the conclusion of allegations for neglect. Unsafe sleep practices, by themselves In the absence of other risk factors, are insufficient to support a finding of substantiated general neglect, but should be considered as a possible part of a pattern of neglect.
Social workers are to consider Safe Sleep Practices when evaluating whether a potential caregiver, whether foster home, relative, or NREFM, is capable of meeting the health and safety needs of infants who may be placed in their care
In all such situations of interaction with caregivers of infants, social workers are to provide information regarding Safe Sleep Practices:

  • Training regarding Safe Sleep Practices is incorporated into education provided to foster parents and prospective foster parents.

  • DFCS provides cards and brochures regarding Safe Sleep Practices, in different languages, for social workers to give to all caregivers of infants with whom they interact.

  • Social workers give resources for securing safe sleep environments to clients with infants.

The role of Resource Family Support includes reminding foster parents about safe Sleep Practices, and to demonstrate safe sleeping arrangements. They also give brochures and First 5 kits.
While community Care Licensing has not promulgated Safe Sleep practices as a foster care licensing regulation, to date, Safe Sleep Practices have been incorporated into:

  • Training for prospective County-licensed foster parents,

  • Orientation for new daycare providers,

  • New foster parent training for Foster Family Agencies (FFA’s).

In instances in which a foster parent refuses to use Safe Sleep Practices, Licensing workers may take action based on failure to provide “Care and Supervision” and/or ‘Conduct Inimical”.



Social workers are to document:

  • That Safe Sleep Practices are included in their assessments of infant safety,

  • That Safe Sleep Practices are included in their instructions and information given to infant caregivers,

  • the infant caregiver’s response to the information given


Other References

Online version of: SIDS and Other Sleep-Related Infant Deaths; Expansion of Recommendations for a Safe Infant Sleeping Environment, American Academy of Pediatrics, along with other information and services, may be Located at:


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