Transition to a Safe Home Sleep Environment for the NICU Patient Michael H

TECHNICAL REPORT

Transition to a Safe Home Sleep Environment for the NICU Patient Michael H. Goodstein, MD, FAAP,a,b Dan L. Stewart, MD, FAAP,c Erin L. Keels, DNP, APRN-CNP, NNP-BC,d,e Rachel Y. Moon, MD, FAAP,f COMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDEN INFANT DEATH SYNDROME

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% abstract < a had low birth weight ( 2500 g [5.5 lb]) and 10% were born preterm Division of Newborn Services, WellSpan Health, York, Pennsylvania; (gestational age of <37 completed weeks). Many of these infants and bDepartment of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; cDepartment of Pediatrics, Norton others with congenital anomalies, perinatally acquired infections, and Children’s and School of Medicine, University of Louisville, Louisville, other disease require admission to a NICU. In the past decade, Kentucky; dNational Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois; eNeonatal admission rates to NICUs have been increasing; it is estimated that Advanced Practice, Nationwide Children’s Hospital, Columbus, Ohio; and between 10% and 15% of infants will spend time in a NICU, fDivision of General Pediatrics, School of Medicine, University of representing approximately 500 000 neonates annually. Approximately Virginia, Charlottesville, Virginia 3600 infants die annually in the United States from sleep-related Drs Goodstein and Stewart and Ms Keels conceptualized and conducted the literature search, wrote and revised the deaths, including sudden infant death syndrome International manuscript, and considered input from all reviewers and the Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), board of directors; Dr Moon conceptualized and revised the manuscript and considered input from all reviewers and the and accidental suffocation and strangulation in bed (W75). Preterm and board of directors; and all authors approved the final manuscript low birth weight infants are particularly vulnerable, with an incidence as submitted. of death 2 to 3 times greater than healthy term infants. Thus, it is This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors important for health care professionals to prepare families to maintain have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through their infant in a safe sleep environment, as per the recommendations of a process approved by the Board of Directors. The American the American Academy of Pediatrics. However, infants in the NICU setting Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this commonly require care that is inconsistent with infant sleep safety publication. recommendations. The conflicting needs of the NICU infant with the Technical reports from the American Academy of Pediatrics benefit necessity to provide a safe sleep environment before hospital discharge from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American can create confusion for providers and distress for families. This technical Academy of Pediatrics may not reflect the views of the liaisons or report is intended to assist in the establishment of appropriate NICU the organizations or government agencies that they represent. protocols to achieve a consistent approach to transitioning NICU infants The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, to a safe sleep environment as soon as medically possible, well before taking into account individual circumstances, may be appropriate. hospital discharge. All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

INTRODUCTION To cite: Goodstein M H, Stewart D L, Keels E L, et al. AAP According to the 2016 policy statement from the American Academy of COMMITTEE ON FETUS AND NEWBORN, TASK FORCE ON SUDDEN Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome, all INFANT DEATH SYNDROME. Transition to a Safe Home Sleep infants, including preterm and low birth weight infants, in the NICU Environment for the NICU Patient. Pediatrics. 2021;148(1):e2021052046 should be placed in the supine position for sleep as soon as they are

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 148, number 1, July 2021:e2021052046 FROM THE AMERICAN ACADEMY OF PEDIATRICS medically stable and significantly optimal growth and maturation of (13%), and when the infant’s before their anticipated discharge the preterm infant can include the respiratory status was stable (6%). from the hospital. In particular, very use of nonsupine positioning, soft Nursing beliefs and knowledge preterm infants should be kept mattresses, and positioners. continue to be a barrier to a culture predominantly in the supine Although developmental care has of consistent safe sleep messaging. A position by 32 weeks’ postmenstrual been shown to be beneficial to the 2016 survey of 96 NICU nurses age (PMA) so that they become long-term neurodevelopmental found that 53% strongly agreed that acclimated to supine sleeping before outcomes of preterm infants, many recommendations make a difference – discharge from the hospital.1 3 of the tools involved in the in preventing SIDS, and only 20% There are many other factors that constantly monitored NICU strongly agreed that parents would define a safe sleep environment to environment are contraindicated model nurses’ behaviors at home.10 minimize the risk of sudden infant after hospital discharge. Transition death syndrome (SIDS), accidental to a safe sleep environment as soon Various reasons are given to explain suffocation and strangulation, and as medically possible, well before why nonsupine positioning and undetermined sleep deaths discharge from the hospital, is other common practices contrary to (collectively known as sudden extremely important because in a safe sleep environment persist unexpected infant death [SUID]), as preterm infants the adjusted odds even when infants are approaching outlined in the same 2016 policy ratio (aOR) for SIDS is 1.85 to 2.72 discharge from the NICU. However, statement. and for suffocation is 1.86 to 2.59 studies find that when expectant or compared with term infants, and the new parents receive education on During NICU hospitalization, infants sleep environment greatly affects infant sleep safety on a consistent are routinely kept in an the risk of these sleep-related basis, their knowledge increases and environment that is not consistent deaths.1,8 their safe sleep behaviors improve, with these recommendations for regardless of the setting (eg, well- numerous reasons, on the basis of Although the AAP through its infant nursery, NICU, Special both treatment of underlying Committee on Fetus and Newborn Supplemental Nutrition Program for pathophysiology as well as the recommended the transition to the Women, Infants, and Children office, normal physiology of the preterm use of the supine position by 32 community health center).11–14 The infant. Pathologic conditions weeks’ PMA3 in 2008, and this purpose of this report is to address resulting in short-term respiratory recommendation was supported by the many issues that result in distress (respiratory distress the AAP Task Force on Sudden conflict with safe sleep guidelines, syndrome and transient tachypnea Infant Death Syndrome in 2011,1,2 looking at the validity of practices of the newborn) or long-term there is long-term and ongoing based on review of the evidence respiratory compromise nonadherence to this regarding pathophysiology and (bronchopulmonary dysplasia and recommendation from NICU normal physiology of the vulnerable pulmonary hypoplasia) result in use providers.3,9,10 Research on infant. The goal of this technical of positioning inconsistent with safe resistance to this recommendation report is not to provide an all- sleep messaging. Other conditions has thus far been focused on only encompassing review of the that may be pathologic, such as NICU nurses. In a 2006 survey of literature for each issue but rather a gastroesophageal reflux (GER), lead 252 NICU nurses, 65% identified summary of data for each issue and to the use of therapeutic prone positioning as the best provide suggestions to resolve interventions such as side-lying general sleep position for preterm conflicting practices. By creating a position and elevation of the head of infants, followed by 12% who consistent approach to transitioning the bed, maneuvers the literature believed either prone or side-lying the infant in the NICU to a safe sleep suggests may be of questionable position was the best sleep environment as soon as medically value.4 To reduce the need for position.9 In addition, the nurses possible, well before hospital narcotic and anxiolytic medications, surveyed were inconsistent discharge, families can be exposed which have been reported to have regarding how they determined to modeling of safe sleep behaviors adverse effects on when a preterm infant is ready to that could decrease the risk of SUID neurodevelopment,5–7 infants with sleep supine. Answers included in this vulnerable population. Areas neonatal opioid withdrawal close to discharge (13%), when of concern include developmental syndrome (NOWS) may be maintaining their body temperature care and/or neurodevelopmental positioned prone or swaddled in an open crib (25%), PMA of 34 to issues, positional plagiocephaly and/ firmly. Developmental care for the 36 weeks (15%), PMA $37 weeks or torticollis, orthopedic issues

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS (developmental hip dysplasia), transition to safe sleep include device to direct and provide respiratory distress, GER and/or positioning, use of positioning aids, therapeutic positioning, leaving the aspiration, thermoregulation, swaddling, and SSC. choice in many cases to the jaundice, and neonatal drug individual nurse or caregiver.34 The Positioning and Use of Positioning withdrawal. Some of this content Infant Positioning Assessment Tool Aids and the advice provided may also be was developed to help provide applicable to infants in the well As the fetus rapidly grows in size caregiver education, standardization, newborn and pediatric inpatient during the third trimester of and evaluation of therapeutic units. pregnancy, the intrauterine positioning.35,36 The Infant environment becomes more Positioning Assessment Tool has DEVELOPMENTALLY SENSITIVE CARE restrictive, and the fetus moves into demonstrated initial validity and a midline position of flexion.29 This Infants born preterm have increased reliability but has not been widely position of the head, shoulder, hip, 35,37,38 risks of poor neurodevelopmental implemented. As the infant outcomes, with risks increasing as and knee flexion; scapular matures and approaches readiness the gestational age decreases.15,16 protraction; and posterior pelvic tilt for discharge from the hospital, an Developmentally sensitive care is a help the fetus develop appropriate interdisciplinary, collaborative, and broad term given to a number of skeletal shapes, flexor muscle tone, thoughtful approach is required to stretch reflexes, and self-regulating determine how and when the use of interventions aimed at modifying 29 the imperfect extrauterine behaviors. With preterm birth positioning devices is discontinued environment to optimize physical comes, among other things, loss of and removed from the infant’s and neurodevelopmental outcomes the physiologic flexion positioning of bedding to achieve a safe sleep 29 for preterm and ill neonates.17 This the intrauterine environment. If environment. Additionally, is achieved through a patient- not supported, the preterm infant communication and education of the centered approach that protects lies flat and asymmetric, with hip infant’s caregivers and family are sleep, manages pain and stress, and joints abducted with abnormal crucial elements to avoid confusion, supports essential activities of daily rotation, unable to bring himself or conflicting information, and living (ie, positioning, feeding, and herself to a flexed and midline inappropriate use of the devices skin care), integrates family and/or position for comfort and self- after discharge from the hospital.39 caregivers into the plans of care, regulation. Over time, this may lead and modifies the physical to musculoskeletal and Many developmental care guidelines environment.17 Conflicting neurodevelopmental abnormalities, include the AAP Safe Sleep information exists about the such as upper extremity recommendations and encourage effectiveness of formalized and hyperabduction and flexion and the transition into a safe sleep programmatic approaches to generalized muscular rigidity. To environment for medically stable developmentally sensitive care.18,19 help prevent these morbidities and infants after the age of 32 weeks’ However, there is evidence that provide comfort and decrease gestation and before discharge from – components of these approaches, measures of stress, neonatal nurses, hospital to home.26 28 However, no particularly skin-to-skin care families, and other caregivers specific time frame has been (SSC)20–22 and breastfeeding,23 therapeutically position the preterm established to meet this goal, promote improved short-term infant in a flexed, midline, and leading to wide interpretation at the – outcomes in response to the contained position, with the head bedside.10,40 42 Some centers have suboptimal environment of the and neck in a neutral posture, developed quality and process NICU. Despite the disagreements in shoulders rounded with hands improvement programs to establish the literature about the effects of brought to the midline, trunk in “C” more concrete timing and increased programs or packages of curve, pelvis in posterior tilt, hips compliance with the Safe Sleep developmental care, integration of and legs in symmetrical and neutral recommendations.43,44 developmentally sensitive care in flexion and rotation, and feet – the NICU has been endorsed by supported.29 31 Therapeutic Impact of Light and Noise Reduction on the Safe Sleep Environment professional organizations,24,25 and positioning is achieved through the formal programs, recommendations, use of various positioning devices NICUs and special care nurseries can guidelines, and quality metrics and supports, such as diapers or be overstimulating to preterm and exist.26–28 Commonly used blanket rolls as well as commercially sick newborn infants. Lighting, noise, – techniques of developmental care available products.30 33 Currently, and temperature can be sources of that may affect the appropriate there is no standardized protocol or noxious stimuli.45–47 In an effort to

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 3 modify the external environment to swaddling should be discontinued and parents to be mindful and decrease stressful stimulation, many when the infant begins to attempt to vigilant of the position of the nurses and caregivers will place a roll over.50,55,56 For a more infant’s airway and the safety of blanket or other covering over the extensive discussion about the caregiver holding to prevent falls infant’sheadofthebed.48 If not well potential risks and benefits of when providing SSC.22,62 If this is secured, these coverings could swaddling, refer to the technical undertaken in the NICU, the infant become loose and cover the infant, report, “SIDS and Other Sleep- should be monitored and secured, increasing the risks of smothering. Related Infant Deaths: Evidence preferably with a conforming wrap The removal of loose blankets in the Base for 2016 Updated carrier. The parent should be crib is an important strategy toward Recommendations for a Safe Infant positioned in a recliner or approved implementing a safe sleep Sleeping Environment” (currently kangaroo care chair or hospital bed environment.1,2 undergoing revision).1 and the kangaroo care provider should be educated by staff about Swaddling Skin-to-Skin Care how this situation differs from the The practice of swaddling infants SSC, or kangaroo mother care, is the home environment. Because of the has been described in many cultures practice of placing the infant’s concerns noted above and the throughout history.49 Infant unclothed chest against the mother’s known dangers of sharing sleep swaddling, in which a cloth or unclothed chest for immediate, surfaces, such as bed-sharing in the device is wrapped around the infant continuous, and sustained contact home environment, adults should be to contain the infant’s body and and exclusive breastfeeding.57 SSC thoroughly educated about the extremities, has been shown to was initially adopted as an dangers of sleeping during SSC. promote sleep49; improve self- alternative to incubators in Conclusions Regarding regulation, particularly in preterm countries with limited resources in Developmentally Sensitive Care infants49; and decrease crying the late 1970s and subsequently time.50 Swaddling also has been demonstrated improved survival for shown to promote supine sleep preterm and low birth weight 1. Developmentally sensitive care is position.51 However, inappropriate infants.58 Now widely adopted in an important component to the use of and/or tight swaddling can countries with both limited and health and well-being of the pre- increase the risks of developmental abundant resources, the practice of term infant. hip dysplasia, cause overheating, SSC has been shown to promote 2. Many of the tools and therapies and restrict breathing. It has been temperature and blood sugar used to promote developmentally associated with vitamin D stability, lower respiratory rate, sensitive care are not consistent deficiency, acute respiratory tract increase oxygen saturation, decrease with a home safe sleep environment. infections, and delayed regain of symptoms associated with mild to 3. It is important to transition in- birth weight and may interfere with moderate pain, and promote fants to a home safe sleep envi- early establishment of maternal bonding and attachment ronment well before discharge breastfeeding.49,52,53 There is a and breastfeeding. These advantages from the NICU. much greater risk of SUID when a may all contribute to overall 4. Good communication with the use swaddled infant is placed in or rolls physiologic and neurobehavioral of a multidisciplinary team is key – – to the prone position.54 56 When development.22,59 61 However, for consistent transitioning of NICU swaddled, preterm infants should be safety concerns have arisen with the patients to a home safe sleep envi- placed in the supine position, have increased practice of SSC. ronment (see A Rational Approach their hands brought to midline Dislodgement of life support to Transition of the NICU Patient to under the chin, and hips and knees equipment and dropping small and a Home Sleep Environment for should be in the flexed position and immature infants, falling out of bed, details). able to move freely.50 Term infants, and airway obstruction have all especially those with NOWS, may been reported. When occurring in DEFORMATIONAL PLAGIOCEPHALY AND benefit from swaddling with arms healthy term or late preterm infants, TORTICOLLIS tucked in the swaddle to reduce these events are referred to as Variations in head shape are often startle response and prevent the sudden unexpected postnatal observed in term and preterm hazard of loose blankets in escaping collapse, which frequently results in infants in the NICU. These head from the swaddle. Because of the death or severe neurologic shape abnormalities can be risk of SUID when swaddled infants impairment.62 These unfortunate secondary to nursing care practices, are in the side or prone position, but real events remind caregivers limitations on positioning, muscle

Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS tone, or other medical conditions CI: 1.58–11.59), low activity level at therapy, need to be in line with safe that can lead to positional or 4 months (aOR: 3.28; 95% CI: sleep recommendations. Devices deformational plagiocephaly 1.16–9.29), and average to difficult that promote a nonsupine sleep (DP).63,64 rating on the Pictorial Assessment of position or have the potential to Temperament test (aOR: 3.30; 95% compromise the airway are not Preterm infants are more CI: 1.17–9.29).70 appropriate. The “Congress of susceptible to developing Neurological Surgeons Systematic plagiocephaly because of decreased Whether congenital muscular Review and Evidence-Based mineralization of the skull bones. In torticollis is the main predisposing Guideline on the Management of addition, they are more likely to factor for DP remains controversial. Patients With Positional have been positioned prone, which Although one study found Plagiocephaly: The Role of may be indicated when the infant is asymmetries of the head and neck to Repositioning” stated that it cannot medically unstable to decrease be common in normal newborn at this time endorse any sleep stress, promote sleep, improve infants, and 16 (16%) of 102 were positioning device because it would 74 feeding tolerance, and enhance found to have torticollis at birth, be contrary to the repeated oxygenation and ventilation. other recent studies suggest that recommendations set forth by the Although therapeutic positioning to cranial shape is more often AAP Task Force on Sudden Infant promote medical stability takes determined by postnatal factors than Death Syndrome to avoid placing precedence during the acute phase prenatal and perinatal factors and any soft surface bedding in the of illness, whenever possible, nurses that most concomitant cervical 78 infant’s crib. Although orthotic should make efforts to choose imbalance (positional torticollis) helmet therapy can be difficult for positions that promote symmetrical develops postnatally along with DP.75 – the parents and can cause side cranial shape.65 67 effects, including sweating, irritation, DP results from unevenly and pain for the infant, they can Since the early 1990s, DP has been distributed external pressure, increasing in prevalence and is resulting in abnormal head shapes. provide significant and faster being more frequently diagnosed. Most cases involve unilateral improvement of cranial asymmetry Most parents and health care occipital flattening, ipsilateral frontal in infants with positional professionals attribute this increase bossing, and anterior shifting of the plagiocephaly compared with to the supine sleep position ipsilateral ear and cheek.76 A rapidly conservative therapy. The Congress recommended for infant safety,68 growing head is malleable and most of Neurologic Surgeons recommends although this has been challenged in susceptible to deformation between a helmet for infants with persistent – recent studies.69 72 It was estimated 2 and 4 months and declines moderate to severe plagiocephaly that 46.6% of 7- to 12-week-old thereafter.70,72,77 Placing the infant after a course of conservative infants had nonsynostotic repeatedly on the same side treatment or if the infant presents at 79 plagiocephaly (NSP) in a Canadian according to infant preferences, as an advanced age. cohort study,72 and in a Swedish well as slower motor development, study in 2009, 42% of 2-month-old are risk factors for the development A recent randomized controlled trial infants had some degree of NSP.73 In of DP. In the NICU, occupational and in Finland evaluated the causal a prospective New Zealand study, physical therapists often make use relationship between DP and there were significant multivariate of various positioning devices and cervical imbalance (positional risk factors for NSP at 6 weeks, supports, such as blanket rolls and torticollis). The intervention group including newborn passive head commercially available products, to was given instructions to create a rotation (aOR: 9.51; 95% confidence prevent progression and to correct nonrestrictive environment that interval [CI]: 2.59–34.94), 6-week DP and torticollis.30–33 However, promotes spontaneous physical sleep position (aOR: 5.27; 95% CI: these therapies are contraindicated movement and symmetrical motor 77 1.81–15.39), and upright time (aOR: when the infant is getting closer to development. The instructions 3.99; 95% CI: 1.42–11.23). At 4 discharge from the hospital, as they focused on 3 areas: alternating head months, risk factors were limited are generally not consistent with position laterally (left and right) passive head rotation at birth (aOR: home infant sleep safety during feeding and sleep, avoiding 6.51; 95% CI: 1.85–22.98), limited recommendations. excessive awake time in supine active head rotation at 4 months position (including prolonged (aOR: 3.11; 95% CI: 1.21–8.05), Many infants with DP undergo placement in car seats and other tried but unable to vary head additional treatment at home. Such devices) in addition to using tummy position at 6 weeks (aOR: 4.28; 95% treatments, including physical time daily, and preventing

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 5 restriction of movement. Infant neck skull bones, as well as more is dislocatable. The clinical stretching exercises were performed prone and side positioning. significance depends on whether the by the parents if an infant showed 3. Positioning devices recommended hip stabilizes, subluxates, or signs of muscular imbalance of the by qualified personnel, such as dislocates and is dependent on neck.77 Infants in the intervention but not limited to occupational many factors, including breech group were less likely to have DP at and physical therapists, can be position, female sex, incorrect lower follow-up, and if present, the used to prevent, control, and cor- extremity swaddling, and positive asymmetry was milder. In addition, rect DP and torticollis while in- family history. Breech presentation infants who had DP were more fants are under continuous may be the single most important likely to have torticollis. This study monitoring in the NICU. risk factor; DDH is reported to occur concluded that early intervention 4.Parentsneedtobeeducatedre- in 2% to 27% of boys and girls – reduces the prevalence and severity garding the use of sleep positioning presenting in breech position.86 88 of DP at 3 months.77 devices: that their use is limited to Other nonsyndromic findings the inpatient setting under strict associated with DDH include being The Finnish randomized controlled monitoring and that they are not the first born, presence of torticollis, trial was similar to a prevention part of a safe sleep environment. foot abnormalities, and project among Swedish child health 5. Orthotic helmets may be appro- oligohydramnios.89,90 nurses that incorporated a short priate for infants with persistent cranial asymmetry prevention moderate to severe plagiocephaly Many mild forms of DDH resolve 80 program. In this study, after a course of conservative without treatment. The clinical hip researchers concluded that treatment or if the infant pre- examination plus or minus education of child health nurses, sents at an advanced age.79 abnormalities on ultrasonography will who in turn educate parents about 6. Parents should be educated to determine the need for an abduction NSP prevention, is successful in avoid excessive use of car seats brace (frequently referred to as a ’ increasing parents awareness of and infant positioning devices Pavlik harness). Potential risks safe interventions to prevent that can promote DP. associated with the use of the Pavlik 80 acquired cranial asymmetry. 7. Education regarding tummy time harness include aseptic necrosis of the should emphasize that it be per- femoral head, temporary femoral nerve These studies provide an evidence- formed during awake, supervised palsy, and obturator (inferior) hip based approach that the parents can 88,91,92 periods only and never when the dislocation. Stopping treatment use to maintain the supine position infant is asleep, even with close after 3 weeks if the hip does not for infant safety while decreasing supervision. reduce and proper strap placement the risk of NSP and/or DP and 8. It is important to transition infants with weekly monitoring are important cervical imbalance (positional to a safe sleep environment well to minimize the risks associated with torticollis). For more information on 93,94 before discharge from the NICU. brace treatment. Some clinicians congenital muscular torticollis, see usedoubleoreventriplediaperingto the 2019 AAP State of the Art manage DDH; although innocuous, it is DEVELOPMENTAL DYSPLASIA OF THE report: Congenital Muscular probably ineffective.95 HIPS Torticollis: Bridging the Gap Between Research and Clinical Clinical hip instability occurs in 1% Transitioning the NICU patient to a Practice.81 For more information on to 2% of term infants, yet up to safe home sleep environment often DP, see the Congress of Neurologic 15% of term infants have hip involves swaddling, which reduces Surgeons Systematic Review and instability or immaturity detectable crying and facilitates better sleep. In 85 Evidence-Based Guidelines for the by imaging studies. Developmental utero, the infants’ legs are in the Patients With Positional dysplasia of the hip (DDH), which fetal position with the knees bent up Plagiocephaly.78,79,82–84 was previously called congenital hip and across each other. Sudden dislocation, is the most common straightening can loosen the joints Conclusions Regarding DP and neonatal hip disorder and is no and damage the soft cartilage of the Torticollis longer considered congenital but socket. Improper swaddling may developmental in origin. The lead to hip dysplasia and should be 1. DP and torticollis occur common- incidence of DDH is approximately 1 avoided in infants with this ly in the NICU environment. to 2/1000 live births, but this diagnosis. Infants should never be 2. The preterm infant is especially estimate does not encompass the placed in prone or side positions at risk for DP because of de- entire spectrum. At birth, an while swaddled. Proper hip creased mineralization of the involved hip is rarely dislocated but swaddling techniques can be found

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS at https://hipdysplasia.org/ It may seem counterintuitive to may contribute to increased tidal wp-content/uploads/2020/05/ place infants with respiratory volume seen with prone positioning. HipHealthySwaddlingBrochure.pdf. distress in the prone position, In the supine position, the because it has been shown to abdominal contents can oppose A leading proponent of swaddling increase the risk of rebreathing excursion of the diaphragm, limiting states that contemporary swaddling exhaled gases, which can result in ventilation. Improvement in techniques permit infants to be hypoxia or hypercarbia.98–101 The oxygenation may be related to snugly wrapped with their hips prone position decreases the rate of improved ventilation-perfusion being safely flexed and abducted.96 heat loss and increases body matching. In the supine position, This position should be encouraged. temperature, putting the infant at some lung tissue is dependent to the An alternative method is to swaddle risk for overheating.102,103 Prone heart and mediastinal structures, only the upper extremities and positioning has been shown to alter increasing the risk of atelectasis in 109,110 allow the lower limbs to move autonomic regulation of the the unstable newborn lung. In freely.97 For a more extensive cardiovascular system, especially in addition to improved lung volume, discussion of the diagnosis and preterm infants, potentially there is evidence of less management of DDH, refer to the decreasing cerebral intrapulmonary shunting and 104–106 improved thoracoabdominal AAP clinical report “Evaluation and oxygenation. Prone synchrony in the prone Referral for Developmental positioning also encourages longer position.111,112 Dysplasia of the Hip in Infants.”85 and deeper sleep periods with fewer awakenings and behaviors In a Cochrane review113 from 2012, Conclusions Regarding DDH associated with stress.107,108 The researchers evaluated positioning SIDS triple risk hypothesis suggests for acute respiratory distress in that some infants who die because 1. Infants are frequently swaddled hospitalized infants and children of SIDS had an intrinsic abnormality in the NICU when approaching using data from 24 studies with a in the brainstem that prevented hospital discharge. total of 581 participants. Although appropriate arousal to an 2. Improper swaddling can lead to the data combined studies of infants environmental threat. All of these or exacerbate DDH. and children, 60% were preterm elements (rebreathing, overheating, 3. Proper swaddling technique infants. Seventy percent of the study and impaired sleep arousal) have should allow the hips to be flexed participants were evaluated while been implicated in increased SIDS and abducted. on mechanical ventilation. Results risk. However, there is some 4. Parents should be well-educated were limited because of lack of data evidence of potential respiratory about all safety issues regarding for many parameters, small benefit with prone positioning. swaddling, in particular the in- participant numbers, and short creased risk of SUID with nonsu- Acute Respiratory Distress study times. There was a small but pine positioning. statistically significant improvement 5. For more information, refer to Once umbilical catheters are in oxygenation (2% higher oxygen 85 removed, one of the commonly used the AAP clinical report on DDH. saturations) when positioned prone. interventions to decrease Prone positioning also provided a respiratory symptoms in the RESPIRATORY DISTRESS (ACUTE AND small improvement in tachypnea, newborn infant is prone positioning. CHRONIC) with a decrease of 4 breaths per Numerous studies have been minute. One of the most common reasons performed to understand what for admission to the NICU is components of ventilation and Although these results are respiratory distress. Some infants oxygenation are affected by prone statistically significant, they may be will have acute respiratory distress positioning, as well as the effects of of marginal clinical relevance. with rapid resolution, such as PMA and degree of illness (acute However, because the extremely transient tachypnea of the newborn, versus chronic lung disease). preterm infant will have a prolonged and others will develop chronic Wagaman et al109 found that prone hospital course in the NICU, the respiratory conditions, such as positioning of preterm infants with benefit of prone positioning during bronchopulmonary dysplasia. Some acute respiratory disease resulted in the acute phase of respiratory infants will have respiratory distress significantly improved arterial illness may outweigh the importance from airway compromise or other oxygen tension, dynamic lung of modeling safe sleep positioning at systemic problems affecting compliance, and tidal volume. that time. Nonsupine positioning can respiration. Improved diaphragmatic excursion still be viewed as a teachable

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 7 moment between clinician and immediately before discharge from in prone position with consideration family. Early safe sleep education the hospital. of using a home monitor with or can be incorporated into without pulse oximetry. Although explanations as to why the infant is The contradiction of improved home monitoring does not prevent positioned nonsupine during acute respiratory function for some or reduce the risk of SUID and is not respiratory distress. preterm infants with the decreased recommended for that purpose, in risk of SIDS or sleep-related deaths this situation monitoring including Chronic Respiratory Distress must be resolved or, as Poets and consideration of pulse oximetry is 119 Fewer data are available for von Bodman noted, we are left appropriate for limiting airway determining any benefits of prone with a “cognitive dissonance obstruction, which could lead to positioning in the convalescent otherwise resulting from parents hypoxic injury or death. Regardless, preterm infant with resolving seeing their infant being nursed in these infants should be managed by pulmonary disease. A small study of the prone position for several weeks a specialized team proficient in the 20 preterm infants (median while being told that they must care of such disorders. gestational age of 30 weeks; range, place their infant supine once at 27–32 weeks) recovering from home.”119 At some point, the Conclusions Regarding Respiratory Distress respiratory distress syndrome diminishing benefits of prone evaluated pulmonary mechanics at a positioning are outweighed by the median postconceptional age of 35 risk of SUID, a leading cause of 1. For the infant with acute respira- weeks.114 In oxygen-dependent postneonatal mortality. Clearly, this tory distress, regardless of gesta- infants, oxygen saturations and needs to be addressed well before tional age, nonsupine positioning functional residual capacity were discharge from the NICU. may be used as clinically indicat- higher in the prone position, but ed to stabilize and/or improve Upper Airway Obstruction there were no differences in respiratory function. compliance or resistance of the Numerous congenital abnormalities 2. If nonsupine positioning is used, respiratory system. In addition, of the airway can result in especially as the infant matures, there were no differences in any of respiratory compromise. Pierre parents should be educated about the measurements for non–oxygen- Robin sequence can be particularly infant sleep safety and the rea- dependent infants. challenging in regard to infant sleep sons for deviating from home safety because of the gravity- safe sleep recommendations. In another study of healthy preterm dependent tongue-based 3. Once the acute respiratory distress infants approaching discharge with obstruction.120 For infants on the is resolving, the infant should be no history of respiratory distress, mildest end of the spectrum who do placed supine for modeling home there was no effect of prone versus not experience significant airway safe sleep, and the parents should supine positioning regarding obstruction while in the supine receive additional education before respiratory rate; tidal volume; position and have normal arterial hospital discharge. minute ventilation; lung compliance; saturations and adequate gas 4. For infants who have developed pleural pressure; or inspiratory, exchange, there is no need to chronic lung disease, periodic as- elastic, and resistive work of deviate from standard safe sleep sessments can be performed to breathing.115 Other studies have recommendations. In the 40% of monitor the infant’s progress. Once shown conflicting results; cases that are severe,120 infants will the infant has weaned to a standard- Hutchinson et al found increased require an inpatient surgical ized minimal supplemental respira- tidal and minute volumes but also intervention, such as mandibular tory support (determined by the increased work of breathing in late distraction osteogenesis, tongue-lip individual institution), then supine preterm infants in the prone adhesion, or tracheostomy, resulting positioning can be maintained, and position.116 Elder et al found no in a stable airway in supine position parents should receive additional impact of position on oxygen at discharge. However, the education before hospital discharge. saturations in preterm infants intermediate cases are more 5. Management of the infant with approaching hospital discharge.117 problematic because they are not upper airway obstruction needs Leipala et al118 found an increase in severe enough for early surgical to be individualized on the basis tidal volume but lower respiratory intervention but require the side or of the severity of the obstruction. muscle strength in the prone prone position for a stable airway. Nonsupine positioning may be compared with the supine position In these cases, it may be appropriate necessary to prevent excessive in preterm infants studied for an infant to sleep on the side or hypercarbia or hypoxemia.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Consideration should be given to were greater decreases in heart rate mild, persistent apnea of home monitoring of the marginal (P 5 .02), longer duration of prematurity. However, they have not airway. bradycardia (P 5 .0003), and longer been found to be protective against accompanying desaturations (P 5 SUID and are not recommended for APNEA OF PREMATURITY .03) when infants were in the supine this purpose. In addition, the use of – Infant apnea is defined by the AAP position. In another small crossover non medical-grade monitors has as “an unexplained episode of design study of 14 stable preterm increased in popularity. As per task 1 cessation of breathing for 20 infants, there was no positional force recommendations, parents seconds or longer, or a shorter difference in the incidence of should be educated that no monitor respiratory pause associated with bradycardia, but there was an takes the place of following the safe bradycardia, cyanosis, pallor, and/or increase in apnea density, defined as sleep recommendations. > marked hypotonia.”121 Apnea can be the number of episodes lasting 6 Conclusions Regarding Apnea and classified as central, obstructive, or seconds during quiet sleep (4.5 vs 5 Prone Positioning mixed, on the basis of airflow and 2.5; P .01), and periodic breathing respiratory effort. The incidence of (percentage of quiet sleep, 13.6% vs 5 apnea is inversely proportional to 7.7%; P .015) when infants were 1. There is inadequate evidence to 127 gestational age. Although all infants in the supine position. justify the use of prone position- born at less than 28 weeks’ ing for the treatment of apnea of gestation will have recurrent apnea, In more recent studies, researchers prematurity. the incidence decreases to 20% by have found either no positional 2. For more information on apnea 34 weeks’ gestation, and these differences in the incidence of apnea of prematurity, refer to the AAP events resolve in 98% of infants by or bradycardia or a reduction in clinical report on apnea of 128,129 40 weeks’ PMA.122 It is unclear as to alarms with supine positioning. prematurity.131 what degree of apnea is considered Bhat et al found preterm infants in acceptable, and there is concern prone position to have more central GASTROESOPHAGEAL REFLUX DISEASE apneas (median: 5.6 vs 2.2; P 5 .04) about the long-term GER is a normal developmental but fewer obstructive apneas (0.5 vs neurodevelopmental effects of process that involves the 0.9; P 5 .007). While supine, the recurrent apnea and periodic involuntary passage of gastric breathing on the preterm infant. infants had more awakenings (9.7 vs 5 contents into the esophagus. GER Measurements of cerebral 3.5; P .003) and arousals per hour (13.6 vs 9.0; P 5 .001).129 These episodes are usually brief, with little oxygenation using near-infrared or no symptoms. Many healthy, term spectrophotometry have studies were also limited by small infants have 30 or more episodes demonstrated decreases in tissue sample size. A 2017 Cochrane review per day of GER and are known as oxygenation during apneic events in identified 5 eligible trials totaling 114 “happy spitters.” Generally, these preterm infants both late in infants in which no statistical episodes dissipate over the first year hospitalization and up to 6 months’ differences were identified between of life as the smooth muscle of the postterm corrected age.105 It has supine and prone positioning with lower end of the esophagus been suggested that intermittent regard to the frequency of apnea, increases in tone with maturation. hypoxia resulting from continuing bradycardia, or oxygen 130 These episodes of GER are classified apnea and periodic breathing can desaturations. The overall quality as transient lower esophageal cause hypoxic cerebral injury123 and of evidence was low, and the sphincter relaxations,132,133 whereas worsening of neurodevelopmental reviewers concluded that they outcomes.124,125 “cannot recommend use of one body pathologic GER, or gastroesophageal position over another for reflux disease (GERD), involves signs Some research has suggested that spontaneously breathing preterm and symptoms of esophagitis with use of the prone position may infants with apnea.” For additional reflux into the esophagus, oral reduce apnea frequency and/or information on apnea of prematurity, cavity, and/or airways. Putative severity. In a small study of 35 refer to the AAP clinical report: morbidities of GERD in preterm preterm infants that used a Apnea of Prematurity.131 infants include frequent vomiting, crossover design placing each infant aspiration pneumonia, irritability, supine and prone, there were Home Monitors failure to thrive, and exacerbations significantly more central and mixed Home monitors are frequently used of respiratory symptoms.134 GER apneas in the supine position.126 In in the NICU setting to allow for and GERD probably represent 2 addition, during mixed apneas, there earlier discharge of infants with ends of a spectrum of the same

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 9 condition, varying with the severity addition, commercially available evaluate the effect of body of the gastric reflux.134,135 formulas that thicken on positioning on GER and acidification in the stomach are not GERD.145–148 Placing the preterm As feeding volume increases and/or nutritionally optimal for the preterm infant in the left lateral position abdominal straining occurs, the infant. Although there is no reason after feeding versus right lateral likelihood of acid reflux episodes to suspect that thickening of feeds position and placing the infant increases.132 The presence of a would work differently in preterm prone versus supine may decrease nasogastric or orogastric tube may as compared with term infants, GER episodes.147,149,150 Although also contribute to GER because its there are few data showing the placement of the infant in the right presence impairs the ability of the efficacy of thickened feeds in this lateral position may increase GER lower esophageal sphincter to population.4 episodes, it may promote gastric completely close, especially in the emptying.150 Prone and lateral first postprandial hour.136,137 According to Salvatore and positioning of infants from birth to Esophageal motility, transit time, Vandenplas in 2002, as many as 12 months is associated with an and gastric emptying are known to 15% to 40% of infants with GER or increased risk of SUID and should be slower in the preterm infant. Full GERD have a cow milk protein be avoided. The risks associated maturation of the intestinal motor intolerance or dietary with prone and/or lateral function does not occur for several protein–induced gastroenteropathy. positioning outweigh any benefit months. Contractions of the After the neonatal period, a trial of gained. Multiple studies in different gastrointestinal tract with feedings an elemental formula may be countries have not shown an are neurally regulated but indicated in infants younger than 1 increase in the incidence of modulated by gastrointestinal tract year if a cow milk protein aspiration since the change to 144 hormones.138 intolerance is suspected. For supine sleeping.151–153 infants receiving human milk, Small enteral feedings (20–24 mL/ similar improvement can be Despite the evidence against kg per feeding) produce a more obtained by restricting all dairy, aspiration in the supine position, mature motor pattern validated by including casein and whey, in the many parents and caregivers remain improved feeding tolerance and mother’s diet.141 Cow milk protein unconvinced.154–162 Coughing or faster gastric emptying and intolerance is most often diagnosed gagging is misconstrued as intestinal transit time.139 in infants on the basis of their aspiration, although it represents Approximately 80% of infants with symptoms and how they respond to the normal protective gag reflex. uncomplicated GER will improve dietary changes. There is evidence The AAP concurs with the North with conservative measures alone, to support a trial of an extensively American Society for Pediatric including small frequent feeds and hydrolyzed protein formula for 2 to Gastroenterology, Hepatology and holding the infant upright for 20 to 4 weeks in term infants, but if no Nutrition that the risk of SUID 30 minutes after feeding. If present, improvement occurs with this outweighs the benefit of prone or removal of a nasogastric or dietary change, the infant’s normal lateral sleep position on GER. orogastric tube may also improve diet can be resumed. Therefore, most infants from birth symptoms of GER.137,140 to 12 months of age should be In the preterm infant, the positioned supine during sleep. In term infants, GER symptoms can persistence of symptoms, despite Elevating the head of the infant’s be abated by avoidance of holding the infant upright for 20 to crib while the infant is supine is not overfeeding and exposure to tobacco 30 minutes, small frequent feeds, effective in reducing GER.163,164 If smoke, change of formula, and the and removal of the nasogastric or the head of the bed is elevated, the 141 use of thickened feeds. orogastric tube if feasible, often infant may slide into positions that Thickening of human milk with leads to the use of therapeutic may compromise the airway and starch is problematic because the interventions, such as side-lying and result in the death of the infant. viscosity decreases over time elevation of the head of the bed. because of amylase in the milk, There is no benefit to elevating the In the 1980s, the US Food and Drug which degrades the starch in the head of the bed, and it should be Administration had approved thickener.142 Care should be taken avoided, especially after discharge, several devices to reduce GER or with thickening feeds for preterm because it may actually increase the positional plagiocephaly. However, infants because a xanthan gum risks of SUID.145 Often, a after reports to the Consumer product has been linked to late- combination of pH and electrical Product Safety Commission (CPSC) onset necrotizing enterocolitis.143 In impedance monitoring is used to of a number of deaths, the Food and

Downloaded from www.aappublications.org/news by guest on September 24, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Drug Administration required seats and other sitting and carrying Gastroesophageal Reflux in Pre- manufacturers to demonstrate that devices.169 term Infants”4). the product benefit outweighed the risk of suffocation.165 Many Safe sleep is paramount during THERMOREGULATION maturation of the lower esophageal manufacturers dropped their claims Temperature regulation in the sphincter, which will abate the of medical benefit, but devices newborn infant is frequently continued to be sold by retailers symptoms of GER with time. referred to as being immature at directly to the public as Therefore, supine positioning is the birth secondary to the lack of non–medical-grade devices. preferred safe sleep position for completely developed infants with GER or GERD. For a thermoregulatory mechanisms, In 2019, inclined sleepers (which more extensive discussion of GER including large surface area-to- are frequently advertised as being and GERD in the preterm and young volume ratios and the relatively beneficial for infants with GER) infant, see the AAP clinical report small insulating body shell.170 As a came under additional scrutiny after “Diagnosis and Management of result of this immaturity, neonates a series of deaths were reported to Gastroesophageal Reflux in Preterm do show greater fluctuations of body the CPSC and additional deaths were Infants”4 or the “Pediatric temperature and difficulty in uncovered in a Consumer Reports Gastroesophageal Reflux Clinical 166 achieving acceptable article. Major manufacturers Practice Guidelines: Joint thermoregulation. voluntarily recalled their products. Recommendations of the North The CPSC issued a statement for a American Society for Pediatric It is well-established that prevention supplemental proposed rule Gastroenterology, Hepatology, and of hypothermia and achieving (Supplemental NPR), proposing to Nutrition and the European Society normothermia in newborn infants adopt the current ASTM for Pediatric Gastroenterology, decreases mortality and optimizes International standard for inclined ”141 Hepatology, and Nutrition. outcomes. Achieving a neutral sleep products, with modifications thermal environment is the goal for that would make the mandatory CONCLUSIONS REGARDING GER AND every patient in the NICU. Achieving standard more stringent than the GERD a neutral thermal environment voluntary standard. The proposed requires that thermoregulatory changes include limiting the seat back angle for sleep to 10 degrees 1. GER is extremely common in in- control be a balance between heat or less.167 fants in the NICU. production and heat loss. Measures 2. Because of the increased risk of to achieve this goal include drying Often, health care providers are SUID, infants should not have the the infant at birth; providing pressured to elevate the head of the head of the bed elevated, nor warmth and insulated surfaces, as bed and/or provide pharmacologic should they be laid down on their needed; providing radiant heat; and interventions despite the lack of side or prone. avoiding cool air currents. In evidence supporting these practices. 3. Term infants can be treated with addition, humidity is routinely used A recent study demonstrated that small, frequent feeds; holding the in incubators in the NICU. Certain infants could more easily roll from infant upright after feeding; clinical scenarios require chemical supine to prone in an inclined thickened feeds; elemental for- mattresses and polyethylene wraps 171,172 sleeper, and once in the prone mula; and removal of the naso- or bags to prevent heat loss. position, they would fatigue faster gastric or orogastric tube, when Hats are also routinely used in the than they would on a stable, flat appropriate. If the mother is pro- delivery room to reduce heat loss. surface because of the high viding human milk, elimination of Estimates of heat loss from the head musculoskeletal demands necessary all cow milk protein from her and face of the newborn infant vary to maintain safe posture to prevent diet may be beneficial. but have been reported at up to suffocation.168 The study also found 4. Preterm infants can be treated as 85%.173 Some estimates, based on that prone positioning on an above, but care should be taken study of clothed adults, may be inclined sleep surface places the to avoid commercial thickeners significantly inflated. An infant infant at higher risk of airway because of the association with simulation study using a heated obstruction or suffocation, as necrotizing enterocolitis. mannequin model found wearing a evidenced by oxygen saturation 5. For more information, refer to hat decreased the local heat loss by results. These results may provide a the AAP clinical report on GER in an average of 18.9% in all clothed mechanism to some of the the preterm infant (“Diagnosis and thermal conditions.174 The type suffocation deaths related to car and Management of of hat used to reduce heat loss is

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 11 important. A simple stocking net hat guideline to avoid coverings generally refers to has been shown to provide minimal overheating.183,184 covering with bedding or bed improvement in temperature.175 clothes. Only one study refers Although data are inconsistent, a Infants should be dressed specifically to hats, finding that polyethylene hat has been shown to appropriately for the although the majority did not wear 175–177 be more effective in preventing heat environment. In term infants, hats, there were significantly more loss in the delivery room for this is usually 1 layer more than an hat-wearing infants among the SIDS 176 preterm infants. In a small study, adult. However, there is significant infants compared with the control researchers found a cotton-wool variation in how preterm infants are infants.187 A systematic review of 10 (Gamgee) material reduced heat loss transitioned from the incubator to population-based, age-matched 177 the open crib, including weight in term infants. controlled studies found the pooled criteria, PMA, number of layers of prevalence of head covering in SIDS Although preterm infants cannot clothing provided, and use of victims was 24.6% compared with regulate their body temperature as wearable blankets and hats.179,180 In 3.2% of controls. The causal well as term infants, their one study, infants were placed in mechanism of this increased risk thermoregulatory ability improves the bassinet with 2 layers of remains unclear, but hypoxia, with maturation.178 Weight-based blankets or a sleep sack and a 180 rebreathing, and thermal stress have criteria for weaning out of the hat. Although the focus during been hypothesized as incubator to a cot or bassinet varies transition to the open bassinet is on 173 from center to center.179–181 A prevention of hypothermia, once the mechanisms. Although it may be Cochrane review in 2011 concluded infant demonstrates temperature unlikely that dislodgement of a hat that transfer to a cot when the stability, providers should turn their could lead to obstruction of an ’ infant attained a weight of 1600 g attention to modeling safe sleep and infant s airway, there may be did not have adverse effects on the dangers of overheating and legitimate concern regarding their temperature stability or weight gain, overbundling. Infants are safest contribution to overheating and/or and earlier weaning from the when they do not sleep with thermal stress. A recent article incubator did not necessarily lead to blankets.173,185 If there is concern questioned the necessity of hats for earlier discharge.182 that the infant will become cold, an preterm infants after initial infant sleeping bag, sleeping sack, or stabilization.188 A chart review of Discharge readiness is usually wearable blanket is recommended 729 infants transitioned out of determined by demonstration of as an alternative to blankets. When supplemental heat without the use functional maturation, including the using a sleeping bag, special care of hats found a failure rate physiologic competencies of should be taken with the preterm attributable to hypothermia of 2.7%. 178 thermoregulation. Often, the infant to ensure they cannot slip Given the questionable benefit of hat ability to increase metabolism and inside and that the head cannot use and the potential for harm, 186 generate heat reaches that of the become covered. Some wearable clinicians should weigh the risk/ ’ term infant before 40 weeks PMA, blankets come with a swaddle benefit ratio in regard to which is reassuring at the time of feature. There is no evidence to discharging an infant from the NICU discharge planning from the NICU. recommend swaddling (wrapping the with a hat. If the infant is discharged Prone sleeping infants have a infant in a light blanket or wearable wearing a hat, the clinician should reduced ability to lose heat, which blanket with a wrap) as a strategy to provide instruction for families to can lead to overheating.102 Evidence 1 reduce the risk of SUID. Refer to the discontinue use once the infant points toward probable differences section on developmentally sensitive demonstrates stable temperatures in in autonomic control of metabolism care for a discussion of the risks and the home environment. This should and cardiorespiratory function in benefits of swaddling. include education about how to the prone versus supine position.170 determine that the infant’s Nonetheless, overheating, as well as Parents and/or caregivers should be temperature is stable. prone positioning, is an educated on evaluating the infant independent risk factor for SUID for signs of overheating, including and must be avoided.1 Although sweating or the chest feeling hot to CONCLUSIONS REGARDING studies have shown an increased the touch.1 Overbundling and THERMOREGULATION risk of SUID with overheating, the covering of the face and head should definition of overheating has varied, be avoided.173 Head covering is 1. Preterm and low birth weight in- making it difficult to recommend a associated with an increased risk of fants are prone to temperature specific room temperature SUID. This increased risk with head instability and may require

Downloaded from www.aappublications.org/news by guest on September 24, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS additional bundling to avoid protection. The phototherapy dose for Health and Clinical Excellence hypothermia. increases as the distance from the (NICE) on this issue.195 The NICE 2. Excessive bundling should be light to the infant decreases. Guideline Development Group avoided because overheating and Spectral power increases as the accepted that, in term infants, the head covering have been associ- amount of skin exposed to position of the infant during ated with an increased risk of phototherapy increases and can be phototherapy has no significant SUID. maximized by using a phototherapy influence on duration of 3. If an infant is discharged wearing blanket under the infant while using phototherapy or mean change in a hat, families should be coun- phototherapy lamps over the infant. serum bilirubin concentration. It seled to discontinue its use once concluded that to ensure consistent When using standard phototherapy the infant demonstrates tempera- advice regarding the risk of SIDS, units, many providers choose to ture stability in the home infants should be placed in a supine rotate the infant between supine environment. position.195 4. If swaddling is performed, it is and prone positioning. Several small studies have been undertaken to important that it is done proper- The NICE recommendation did not evaluate the utility of changing the ly, the infant is always placed su- include preterm infants, because it position of the neonate during pine, and it is discontinued when was released before the most recent phototherapy, and no benefit in the infant begins to attempt to studies that included infants as early relation to decrease in bilirubin roll. – as 33 weeks’ gestation. However, the concentrations was found.191 193 All consistency of the results in both recent studies have been evaluated HYPERBILIRUBINEMIA AND term and middle-to-late preterm PHOTOTHERAPY in a systematic review that also concluded that supine positioning is infants should provide clinicians Hyperbilirubinemia is an extremely as effective as turning infants with confidence in maintaining these common problem in both the term periodically.192 Two more recent infants in a strictly supine position if and preterm infant. During the first and larger trials provide additional there is no other contraindicating week of life, up to 60% of term evidence suggesting that positional medical condition. Modeling the newborn infants and 80% of change is unnecessary for successful supine position is a powerful tool in preterm infants will develop use of phototherapy. Donneborg the education of families regarding jaundice because of the immaturity included infants as young as 33 infant sleep safety and SUID risk of the liver, leading to elevated weeks’ gestation and used higher reduction. These more mature concentrations of circulating light irradiance compared with older preterm and term infants are likely 189 unconjugated bilirubin. Beyond studies.193 The study demonstrated to have short stays in the NICU, so the common physiologic jaundice of identical rates of decrease in total early modeling of safe sleep is more the newborn infant, there are many serum bilirubin at 12 and 24 hours pressing, and the use of hemolytic conditions and other after initiation of phototherapy, phototherapy should not interfere abnormalities that can lead to regardless of supine or alternating with supine sleep positioning.196 excessive jaundice. Nomograms are positioning. Most recently, available to help the clinician detect 194 Bhethanabhotla et al studied 100 CONCLUSIONS REGARDING which term and late preterm infants infants of greater than 34 weeks’ PHOTOTHERAPY are at higher risk of going on to gestational age and found no develop excessive jaundice that difference with or without 1. Hyperbilirubinemia and the use untreated could lead to kernicterus positioning in the duration of of phototherapy is common in and permanent bilirubin phototherapy or the rate of decrease 190 term and preterm infants in the encephalopathy. in total serum bilirubin NICU. concentration. The mainstay of therapy for 2. There is no benefit to changing ’ neonatal unconjugated Although the AAP guideline an infant s position while under hyperbilirubinemia is phototherapy. “Management of Hyperbilirubinemia phototherapy. However, the pro- The factors that affect the dose of in the Newborn Infant 35 or More vider may choose to place the in- phototherapy are the irradiance of Weeks of Gestation” did not fant on a bilirubin blanket, in the light used, the distance from the comment on positioning of the addition to an overhead photo- light source, and the amount of skin infant during phototherapy, there is therapy unit, if the absolute total exposed.189 The infant should be an analysis and statement from the serum bilirubin concentration is naked except for diaper and eye United Kingdom’s National Institute increasing rapidly, in effect,

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 13 performing double-sided article, such as improved neurologic study has implicated opiates in phototherapy. regulation, establishment of sudden infant death, with maternal 3. Unless there are other competing breastfeeding, and maternal methadone use identified in 31% of medical issues, infants should be bonding.200 One of the benefits of 32 neonatal deaths evaluated by kept supine while receiving pho- SSC is to enhance breastfeeding,204 autopsy.207 It is unclear whether the totherapy to model and promote which in turn has been shown to deaths were directly related to the infant sleep safety. decrease the severity of NOWS methadone or other environmental symptoms, days of pharmacologic factors. In addition, the frequent NEONATAL OPIOID WITHDRAWAL treatment, and hospital stay.198,205 occurrence of polysubstance use (eg, SYNDROME Current recommendations support tobacco and alcohol) among those NOWS is a clinical condition breastfeeding when the mother is who use opioids further increases observed in neonates experiencing compliant with maintenance the risk of sudden infant death, therapy.197 particularly associated with bed- withdrawal from in utero opiate 208–210 exposure.197 Symptoms caused by sharing. Thus, presence of maternal substance use disorder central nervous system irritability, The importance of not falling asleep warrants extensive safe sleep autonomic nervous system with the infant during SSC, education before discharge from the dysfunction, and gastrointestinal especially after hospital discharge, hospital. and respiratory tract distress should be stressed with opioid- typically appear 2 to 3 days after dependent parents. The opioid- Swaddling is frequently used in the birth and can last for weeks or dependent parent falling asleep with care of infants with NOWS and months.197 Although opiate the infant would be analogous to bed-sharing with someone who is seems to be an effective therapeutic replacement therapy may be intervention for this population. indicated on the basis of the impaired in his or her alertness or ability to arouse because of sedating Although no studies specifically severity of clinical presentation, the address swaddling and infants with foundation of treatment and support medications, which greatly increases the risk of SIDS.1 Falling asleep with NOWS, it is believed the of the infant with NOWS is directed intervention may be useful to the infant during SSC is of particular at supportive, nonpharmacologic decrease excessive crying and concern for the mother of an infant care aimed at minimizing the promote sleep.198,199,211 Refer to the with NOWS, because during stimulation that is being section on developmentally sensitive pregnancy, women often require experienced and/or supporting the care for additional information on 198,199 increases in methadone dosing infant to self-regulate. These benefits and risks of swaddling. measures include promoting SSC,200 because of factors such as increased – rooming-in and breastfeeding,201 203 intravascular volume and increased Swings and motion devices are decreasing light and noise,200 tissue reservoir and hepatic commonly used in NICUs, well 206 swaddling and positioning,200 use of metabolism of the drug. The newborn units, and pediatric pacifiers and/or rockers,200 and optimal approach to methadone inpatient units to calm fussy infants, massage.200 Many of these dose management in the postpartum particularly those suffering from interventions, commonly associated period, however, is not well defined, NOWS. Rocking devices have been with developmentally sensitive care, and there is the theoretical concern used through the ages for their previously described in this report, that methadone concentrations may calming effect on crying infants. have variably been shown to help increase as plasma volume and Although not extensively studied, support preterm infants’ hepatic clearance return to the there are reports demonstrating the neuroregulation, decrease length of prepregnant state. Yet in a study of consoling effect of rocking.212,213 medical treatment, and decrease 101 methadone-maintained The data are inconsistent regarding hospital length of stay.198,200,203 pregnant women, researchers found direction of the movement, and one Despite a paucity of evidence, these no significant increase in study showed more benefit by interventions are being used to help oversedation events: after adjusting rocking at 60 cycles per minute support infants struggling with for benzodiazepine prescriptions, versus 45 cycles per minute.213 A NOWS.198,200,203 the incident relative rate of an event recent study showed benefit of among postpartum women rocking by either a parent or SSC has been recommended as a compared with pregnant women mechanical device, although rocking strategy to help support infants with was 1.74 (95% CI: 0.56–5.30).206 by the parent appeared to be more NOWS for many of the same reasons Nevertheless, opioid exposure is still effective.214 It is important that staff as previously mentioned in this of concern because a retrospective use motion devices appropriately,

Downloaded from www.aappublications.org/news by guest on September 24, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS while infants are awake and CONCLUSIONS REGARDING NOWS risk of SUID by 40% (relative risk properly monitored. In addition, 0.60 [0.44–0.82]).224 infants should be moved to a safe 1. There are some commonly used sleep environment if they fall asleep interventions in the treatment of The reduction in risk of SUID from in a swing or motion device, because NOWS (ie, prone positioning) that human milk may be multifactorial. these are not considered safe sleep are not consistent with home in- Human milk has biologically active surfaces. Although infants are under fant sleep safety. components that are constant monitoring in the NICU 2. Early and frequent education is immunoprotective through their environment, leaving a sleeping critical to prevent families from antimicrobial and infant in a swing or motion device is thinking that therapeutic inter- immunomodulatory activity. Among poor modeling for families and ventions in the hospital that are the many components are white undermines safe sleep messaging. not consistent with home infant blood cells, stem cells, safe sleep guidelines can be repli- immunoglobulins (especially There is some evidence that placing cated in the home environment. secretory immunoglobulin A), infants who are experiencing lactoferrin, lysozyme, and human 3. The use of therapeutic interven- 225,226 narcotic withdrawal in the prone tions that are not consistent with milk oligosaccharides. The position decreases the severity of home infant sleep safety should decrease in viral infections (which NOWS scores as well as caloric have been associated with an 215 be minimized. When they are 1 intake. As described previously in necessary, it is important to re- increased risk of SUID ) may this article, prone positioning may view their use and transition to a partially explain this protective increase the risks of musculoskeletal effect of human milk. In addition, 108 safe sleep environment as early abnormalities as well as SUID, is as possible. polyunsaturated fatty acids in not consistent with AAP safe sleep 4. Clear, consistent, safe sleep mes- human milk, in particular recommendations, and is not saging should be emphasized docosahexaenoic acid, are important recommended as a strategy to with families of infants with in the overall maturation of the console infants with NOWS outside NOWS well in advance of dis- central nervous system, especially of a monitored unit. Prone charge from the hospital. the cardiorespiratory center, and positioning may be useful for myelination of the brain.227–230 In monitored inpatients during the one study, infants who died of SIDS HUMAN MILK AND BREASTFEEDING acute withdrawal phase of NOWS had delayed myelination of the brain but should be discontinued, and Although not directly related to the compared with control infants.231 the patient should be placed in transition to safe sleep, a discussion supine position as soon as possible about infant sleep safety is not Given the increased risk of SUID in and before discharge from the complete without mentioning the preterm infant, breastfeeding hospital. breastfeeding and human milk and the use of human milk after feeding. The benefits of discharge may be even more The time that the infant may need breastfeeding are numerous, important in this population. these interventions focused on including decreased risk of infection; However, successful maternal milk neurodevelopmentally sensitive care decreased risk of allergies, asthma, production is dependent on early will depend on the length and and eczema; decreased risk of initiation, and in the case of the severity of NOWS symptoms. obesity, inflammatory bowel disease, preterm or term infant with Particularly in infants whose NOWS high cholesterol, and type I diabetes respiratory distress, it requires the symptoms seem to worsen without mellitus; and possibly decreased risk mother to provide expressed milk these interventions, transition to of some childhood cancers.216 In through pumping or hand safe sleep practices before discharge addition, in preterm infants, human expression. As a result, clinicians from the hospital often presents milk has been shown to improve need to provide education regarding challenges to NICU clinicians and feeding tolerance and reduce the the benefits of breastfeeding on families. Each center caring for risk of necrotizing admission to the NICU, or earlier if – infants with NOWS should develop enterocolitis.217 220 Multiple studies possible,232 and work in and implement a standardized have shown that breastfeeding is multidisciplinary teams to enhance process to identify when the infant associated with a decreased risk of support for breastfeeding, milk – has reached medical stability and SUID.221 223 A recent meta-analysis expression, and provision of transition to safe sleep found that providing term infants mother’s milk throughout the NICU recommendations before discharge with any human milk for at least the stay.233 Furthermore, preterm from the hospital. first 2 months of life decreased the infants and their mothers require

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 15 significant support when they are maternal fatigue. If the mother or optimize breastfeeding success discharged from the hospital and caregiver is tired or sleepy while after discharge from the hospital. transition to direct breastfeeding in holding the infant, the infant should the home setting.234 be moved to a separate sleep A RATIONAL APPROACH TO TRANSITION surface.62 OF THE NICU PATIENT TO A HOME Finally, as noted in the previous SLEEP ENVIRONMENT discussion on SSC, it is critical that This can be an opportunity for open, Consistent messaging and modeling parents be aware of the dangers of nonjudgmental discussion regarding in the newborn nursery have been falling asleep with their infant. This ’ the family s infant sleep safety plan shown to improve parental intent to is especially important when for home. The AAP 2016 policy keep infants supine and not share mothers are rooming-in with their – statement on SIDS recommends sleep surfaces.11,242 244 In the NICU infant and not under constant room-sharing with the infant on a environment, McMullin et al found observation by NICU staff. Although 2 separate sleep surface. The policy that a bundled intervention for it is often stated that breastfeeding also states numerous conditions nursing can lead to consistent naturally results in maternal under which bed-sharing is modeling of safe sleep before drowsiness from the release of particularly dangerous. And even in hospital discharge. The intervention prolactin and oxytocin, there are situations in which there are no included nursing education, crib few data to support this other risk factors, there is some cards, written instructions reviewed concept.235,236 Breastfeeding evidence of increased risk with bed- with parents, and sleep sacks for mothers are often exhausted in the sharing, especially in the youngest modeling to parents. Audits 6 early days and weeks from sleep age groups and among those who months after the intervention found deprivation and disruptions in their were born preterm or with low 98% of infants supine in open cribs, normal circadian rhythms. In a 2019 birth weight. Sample size limitations 93% of infants in sleep sacks, and study, researchers found that after prevent a determination of how delivery, new mothers averaged 3.7 88% of bassinets with safe sleep large that risk is, but clearly the crib cards visible.245 hours of sleep, and the longest data do not support a definitive interval of sleep observed was conclusion that bed-sharing in the Standardized programs have also between 2 and 3 hours throughout youngest group is safe, even under demonstrated higher rates of supine the postpartum hospital course.237 less hazardous circumstances. For sleep and other safe sleep behaviors Of the 101 participants, 50 required additional information, refer to both in the home.246,247 Given that 20% at least 1 intervention or corrective the AAP clinical report “Safe Sleep of SUID cases involve preterm action to address unsafe sleep.237 and Skin-to-Skin Care in the infants and preterm infants are at a Neonatal Period for Healthy Term Mothers may also be emotionally or twofold to threefold increased risk Newborns”62 and AAP technical 248–250 physically exhausted from the stress of SUID, it is critical that report “SIDS and Other Sleep- and other demands of a NICU families of infants in the NICU be Related Infant Deaths: Evidence hospitalization.238 The risks for exposed to safe sleep environmental Base for 2016 Updated infant falls or smothering are modeling and education for a Recommendations for a Safe Infant analogous to those seen with successful transition to a safe sleep Sleeping Environment.”1 rooming-in on the well newborn environment in the home. The AAP unit with healthy mother-infant through its Committee on Fetus and dyads. Studies have observed CONCLUSIONS REGARDING HUMAN Newborn recommends that associations between postpartum MILK AND BREASTFEEDING “preterm infants should be placed sleepiness and fatigue and decline in supine for sleeping, just as term cognitive neurobehavioral 1. The use of human milk is recom- infants should, and the parents of functioning.239,240 Education of staff mended for its numerous health preterm infants should be counseled and families is crucial, and staff benefits, including reducing the about the importance of supine should also take care to evaluate the risk of SUID. sleeping in preventing SUID. mother’s level of sleepiness.238,241 2. Special care should be taken Hospitalized preterm infants should The risk of falls and sudden when mothers are rooming-in be kept predominantly in the supine unexpected postnatal collapse and breastfeeding to minimize position, at least from the should be minimized by conducting the risk of falling asleep with the postmenstrual age of 32 weeks frequent assessments and infant in the adult bed. onward, so that they become monitoring of the mother-infant 3. Provide mothers with appropri- acclimated to supine sleeping before dyad and evaluating the level of ate outpatient support to discharge.”3

Downloaded from www.aappublications.org/news by guest on September 24, 2021 16 FROM THE AMERICAN ACADEMY OF PEDIATRICS However, as outlined in this was defined by 4 parameters: traditionalists who prefer the status document, not all infants will be supine positioning; a flat crib with quo. Resistance to change is clinically ready to be maintained in no incline; no positioning devices; common, so consensus building is a safe sleep environment by 32 and no toys, comforters, or fluffy essential to success. Ideally, the weeks’ PMA. Algorithms that blankets. Compliance increased from components of change should be account for some of the variables 48% at the start of the project to developed by a multidisciplinary discussed in this report have been 76% at 1 year and 81% by 2 years. team to reflect input from developed on the basis of literature Three of the individual components physicians, nursing, lactation review, expert opinions, and unit had compliance greater than 90% at consultants, respiratory therapists, consensus.14,251 Quality the end of the study. and development therapists improvement programs using these (physical therapists, occupational algorithms can result in both more Many states have been focusing therapists, and speech therapists). consistent modeling in the NICU and efforts on hospital-based Having access to local, state, and improved parental compliance with interventions to promote safe sleep national statistics regarding SUID safe sleep practices. Hwang et al251 behaviors, anticipating that the can facilitate breakdown of barriers showed a pre- to postintervention downstream effect will be a to promoting consistent safe sleep improvement with overall safe sleep decrease in SUID and infant sleep- education and modeling. Statistics environmental compliance in 2 related deaths. Some studies and can be obtained through multiple community NICUs from 25.9% to epidemiological data support this sources, including state departments tactic. In Tennessee, Heitmann et al 79.7% (P < .001). In another study, of health; the Centers for Disease analyzed a Department of Health NICU compliance with supine Control and Prevention, through program to implement a safe sleep positioning increased from 39% to CDC Wonder linked birth and infant policy at all 71 birthing hospitals in 83% (P < .001), provision of a firm death records (https://wonder.cdc. the state. Audits revealed a 45.6% sleeping surface increased from 5% to gov/lbd.html); and yearly state child decrease in infants found with any 96% (P 5 .001), and the removal of death review reports. In addition, risk factors for unsafe sleep. There soft objects from the bed improved hospitals can work together with lo- were significant decreases in infants from 45% to 75% (P 5 .001). cal coroners, medical examiners, and found asleep nonsupine, with a toy Furthermore, parental compliance child death review teams to provide or object in the crib, and not with safe sleep practices in the days feedback on the effectiveness of sleeping in a crib.253 after discharge from the NICU safety efforts. One study demon- strated the efficacy of a sustained improved from 23% to 82% Creating a culture of infant sleep (P < .001). The largest improvements quality improvement effort that safety in the NICU setting can be linked outcome data from local child involved placing infants supine for challenging. At the institutional level, fatality review teams. The average sleep (93% vs 73%), dressing infants diffusion of innovation theory can death rate decreased from 1.08 in- appropriately (93% vs 66%), and help guide culture change. Successful fants per 1000 births preinterven- removing extra soft blankets from the quality improvement efforts require a 14 tion to 0.48 infants per 1000 births crib (97% vs 61%). team of key players, including (1) after complete intervention with opinion leaders, the respected leaders feedback from child fatality review Although many of the studies who have influence over others; (2) teams and performance improve- showing improvement in modeling change agents, the key people who ment methodology.254 The authors safe sleep have been single-center support change, stabilize adoption, concluded that repeated messaging studies, a recent evaluation by and solve problems; and (3) change 252 and education by the entire nursery Hwang et al of a statewide aides, trustworthy people on the front staff has the potential to play a role quality improvement project, lines who help maintain change. including 10 level III NICUs in in reducing sleep-related deaths in infants born at a hospital. Massachusetts, not only confirmed In addition, people respond the utility of an integrated approach differently to change, so it is to safe sleep in the NICU but also important to seek out the innovators CONCLUSIONS demonstrated that it can be or risk takers who like new things As clinicians, we must find equipoise amplified across institutions at the and the early adopters who accept between the acute physiologic needs state level via perinatal quality change readily. It is equally of the infant and the inevitable collaboratives. Over a 2-year period, important that change agents and necessity to provide a home safe 7261 cribs were audited for aides work closely with the late sleep environment before discharge compliance with safe sleep, which majority or skeptics and the from the hospital. There are many

PEDIATRICS Volume 148, number 1,Downloaded July 2021 from www.aappublications.org/news by guest on September 24, 2021 17 competing and conflicting needs for Society STAFF – the NICU patient and family. Russell Miller, MD American College of James Couto, MA Preterm infants are at increased risk Obstetricians and Gynecologists RADM Wanda Barfield, MD, MPH, FAAP – of SUID, so as providers, we should Centers for Disease Control and Prevention focus on sharing regular, repetitive, Lisa Grisham, APRN, NNP-BC – National and consistent education with Association of Neonatal Nurses ABBREVIATIONS families throughout the AAP: American Academy of hospitalization. Through our STAFF Pediatrics messaging with not only our words Jim Couto, MA aOR: adjusted odds ratio but also our modeling behaviors, we CI: confidence interval will enable NICU families to be CPSC: Consumer Product Safety properly prepared for the transition TASK FORCE ON SUDDEN INFANT Commission home to a safe sleep environment. DEATH SYNDROME Rachel Y. Moon, MD, FAAP, Chairperson DDH: developmental dysplasia of the hip LEAD AUTHORS Elie Abu Jawdeh, MD, PhD, FAAP Rebecca Carlin, MD, FAAP DP: deformational plagiocephaly Michael H. Goodstein, MD, FAAP Jeffrey Colvin, MD, JD, FAAP GER: gastroesophageal reflux Dan L. Stewart, MD, FAAP Michael H. Goodstein, MD, FAAP GERD: gastroesophageal reflux Erin L. Keels, DNP, APRN-CNP, NNP-BC Fern R. Hauck, MD, MS Rachel Y. Moon, MD, FAAP disease NICE: National Institute for CONSULTANTS COMMITTEE ON FETUS AND NEWBORN, Health and Clinical 2019–2020 Elizabeth Bundock, MD, PhD – National Excellence Association of Medical Examiners NOWS: neonatal opioid James Cummings, MD, FAAP, Chairperson Ivan Hand, MD, FAAP withdrawal syndrome Lorena Kaplan, MPH – Eunice Kennedy Ira Adams-Chapman, MD, MD, FAA NSP: nonsynostotic plagiocephaly Shriver National Institute for Child Health PSusan W. Aucott, MD, FAAP PMA: postmenstrual age and Human Development Karen M. Puopolo, MD, FAAP SIDS: sudden infant death Jay P. Goldsmith, MD, FAAP – syndrome David Kaufman, MD, FAAP Sharyn Parks Brown, PhD, MPH Centers Camilia Martin, MD, FAAP for Disease Control and Prevention SSC: skin-to-skin care Meredith Mowitz, MD, FAAP SUID: sudden unexpected infant – Marion Koso-Thomas, MD, MPH Eunice death Kennedy Shriver National Institute for Child LIAISONS Health and Human Development Timothy Jancelewicz, MD, FAAP – American Academy of Pediatrics Section on Surgery Carrie K. Shapiro-Mendoza, PhD, MPH – Michael Narvey, MD – Canadian Paediatric Centers for Disease Control and Prevention

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. DOI: https://doi.org/10.1542/peds.2021-052046 Address correspondence to Michael Goodstein, MD, FAAP. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright # 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 26 FROM THE AMERICAN ACADEMY OF PEDIATRICS Transition to a Safe Home Sleep Environment for the NICU Patient Michael H. Goodstein, Dan L. Stewart, Erin L. Keels and Rachel Y. Moon Pediatrics 2021;148; DOI: 10.1542/peds.2021-052046 originally published online June 21, 2021;

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 Transition to a Safe Home Sleep Environment for the NICU Patient Michael H. Goodstein, Dan L. Stewart, Erin L. Keels and Rachel Y. Moon Pediatrics 2021;148; DOI: 10.1542/peds.2021-052046 originally published online June 21, 2021;

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