The ABCs of Safe Sleep

A team of nurses at Johns Hopkins Children’s Center is on a mission to ensure every baby slumbers safely: 'Alone on their Back in a Crib'.

Published in Hopkins Children's - Fall 2022

It began as a quest to find grant money to buy sleep sacks for families to use at home when their babies are discharged from Johns Hopkins Children’s Center. Sleep sacks are safer and more convenient than blankets, says pediatric nurse Catherine Ehrhardt. A baby can’t get accidentally tangled in them, or end up with a blanket covering its face. 

But for Ehrhardt and her colleagues on Bloomberg 9 South, that 2017 quest turned into a far more ambitious mission: to position the Children’s Center at the forefront of the campaign to model and promulgate “safe sleep” for babies.

In the course of her research, Ehrhardt realized that while she and her colleagues were sending new parents home with up-to-date safe sleep recommendations from the American Academy of Pediatrics (AAP) — which research has shown can prevent accidental deaths and SIDS (sudden infant death syndrome) — it was equally important to ensure these recommendations were consistently modeled inside the hospital.

“While we always want to provide comfort to our infant patients, items such as blankets, toys and stuffed animals in the sleeping environment can put babies at risk,” she says.

So Ehrhardt and her 9 South nurse colleagues Amy Hess and Molly Rye launched a campaign to assess infant safe sleep practices, first in their unit — the acute medical surgical unit for infants and toddlers — and then throughout the Children’s Center, as well as the newborn nursery at The Johns Hopkins Hospital. They recruited “safe sleep champions” in each of those units, created hospital policies to align with the latest American Academy of Pediatrics guidelines, and educated their colleagues about safe sleep and why it matters.

Though the campaign was interrupted by COVID-19, they relaunched their efforts last June with a weeklong Safe Sleep Blitz, complete with demonstrations, a trivia quiz, buttons and safe sleep badges for nurses to wear, reminding them of the essentials or “ABC’s” of safe sleep for babies: “Alone on their Back in a Crib.”

And they are now ready to apply for the Cribs for Kids National Safe Sleep Hospital Certification program, which would make The Johns Hopkins Hospital only the second hospital in Maryland to become a nationally certified Safe Sleep Hospital.

"We are applying for gold certification, the highest of the three tiers for certification that Cribs for Kids offers,” Ehrhardt says.

Why ‘Safe Sleep’ for Babies?

Even before scientists first gave it a name in 1969, SIDS or sudden infant death syndrome, sometimes known as “crib death,” was a source of underlying anxiety for new parents. By definition SIDS is a mystery. A baby dies suddenly, usually in his or her sleep, and a thorough investigation, including an autopsy, yields no known cause. And though such deaths are relatively rare — around 1,300 occur each year in the United States, according to the Centers for Disease Control and Prevention — SIDS continues to be a leading cause of death among babies 0 to 12 months old.

Though the cause of SIDS is still unknown, there is strong evidence that safe sleep recommendations first introduced by the American Academy of Pediatrics in 1992 — which included the then revolutionary mandate that babies should sleep on their backs — had a dramatic preventive impact. SIDS declined from some 130 cases per 100,000 live births in 1990 to around 38 in 2020, according to the CDC.

Yet while those numbers dropped sharply in the 1990s, there has been no further improvement since 2000. Even more alarming, researchers have found that African American and Native American babies are more than twice as likely to die of SIDS as white babies. Some research has suggested a need for more culturally sensitive education about safe sleep practices in these communities, as well as funding for safe sleep spaces for babies whose parents don’t have the means to provide them.

Cribs for Kids was launched in Pittsburgh in 1998 with the mission of providing portable cribs for at-risk families and educating parents on the dangers of unsafe sleep environments. In Baltimore, B’more for Healthy Babies, an innovative partnership between the city’s health department and more than 100 participating organizations, including the Johns Hopkins Center for Communications Programs, also provides safe sleep education and helps eligible families obtain free cribs.

SIDS is just one cause of what researchers call sudden unexpected infant death (SUID), which also includes accidental sleep-related deaths from suffocation or strangulation. The CDC estimates that there are some 3,400 of these unexpected deaths in the U.S. every year, and safe sleep practices have been shown to help prevent them as well. As with SIDS, the highest SUID rates by far are among African American and Native American babies, the lowest among Asian and Hispanic babies, with white babies somewhere in the middle.

An Uncluttered Crib

The AAP updated its guidelines in July (see sidebar) and Ehrhardt’s safe sleep team at the Children’s Center incorporated those updates in educational materials and policies throughout the hospital.

The essence of those guidelines is captured in a logo Ehrhardt’s team likes to use, with the letters ABC above a sleeping baby:

  • Alone: Co-sleeping, whether it be with parents or caregivers on a sofa or a recliner or in bed, dramatically increases the risk of infant sleep-related death, according to the AAP.
  • Back: Babies should be put to sleep on their backs.
  • Crib: Babies should always sleep in a crib or bassinet on a firm mattress covered with a snugly fitted sheet. If a baby falls asleep in a car seat or bouncy chair, he or she should be moved to the crib as soon as possible.

The crib itself should be completely uncluttered, no pillows, extra blankets, bumper pads, toys — nothing the baby can press its face against or get entangled with that might interfere with breathing.

Other risk factors include smoking around a baby, using sedatives, alcohol, marijuana and other substances that potentially impair judgment, and overheating a baby with blankets or hats or extra layers of clothing.

But there are also positive things parents can do. Breastfeeding, offering babies pacifiers once breastfeeding has been established, and even adhering to a baby’s recommended vaccination schedule are all associated with a lower risk of sleep-related death. And while babies should not share a bed with parents, sharing a room has also been linked to lower risk of infant death.

Modeling Safe Sleep

Nurse manager Dörte Thorndike says she was delighted when Ehrhardt approached her about modeling safe sleep practices in the Children’s Center. “It was a wonderful idea,” Thorndike says. “We decided to begin with a pilot program on our own 20-bed unit.”

The nurses collected data on current practices, trained all of the nurses on the unit, talked to new medical residents about safe sleep, ordered fitted sheets and sleep sacks, agreed on a rollout date, and developed an audit tool to regularly check on each infant in the unit with a list of questions to determine the baby’s safe-sleep status. “It took about a year to get everything in place,” Thorndike says. At the end of the year they surveyed the nursing staff and got a thumbs-up. Nurses not only confirmed the value of the new protocols, they thought the initiative was helping families.

A year later, the team did similar rollouts on every unit that cares for babies. They even trained other members of the medical team, from occupational and physical and respiratory therapists to child life specialists.

Then COVID-19 hit. “It sort of took the wind out of our sails,” says Rye, who was new to the unit when the safe sleep program was taking off in 2017 and had become devoted to the cause.

Last spring they were ready to pick up where they’d left off. Ehrhardt and Rye attended the annual Cribs for Kids conference in Pittsburgh and came back newly inspired — by researchers and activists passionate about promoting safe sleep, and parents who’d lost their babies and decided to channel their grief into helping other families avoid a similar fate.

The nurses also came back with a safe sleep simulation doll designed to show skeptical parents the anatomical reason babies are less likely to choke when they spit up if they are sleeping on their backs. When a baby is on its back, the baby’s windpipe lies on top of the esophagus. Anything regurgitated from the stomach through the esophagus has to go against gravity to get to the windpipe and cause choking. When a baby is on its stomach, these fluids leave the baby’s esophagus and pool at the windpipe opening, making choking more likely.

“Sometimes parents are resistant to safe sleep recommendations, often because it’s different from how they were raised,” Rye says. “But once they understand the reasons they’re usually completely on board. And a lot of us learn best by actually seeing something. I know I do.”

A month later, the team organized a Safe Sleep Blitz Week “to make a big deal about safe sleep and get people excited about it again,” Rye says. They visited each baby-serving unit with a cart piled high with educational materials, a trivia game and prizes. “It was fun,” Rye says. “Everyone wanted to play.”

And Hess, who came to 9 South eight years ago and has also advocated for the safe sleep initiative from the beginning, says, “It was really just a great way to get more information out there and spread awareness. A lot of the units set up their own safe sleep displays and some were really creative. One unit did two contrasting bassinets — an unsafe sleep bassinet and a safe sleep bassinet — using realistic-looking baby dolls, which was really cool and caught everyone’s attention, including the parents. Like ‘what is this baby doing in the hallway?’ We’d like to do it every year, probably in October, which is Safe Sleep Awareness Month.”

Rye is working on a Spanish language safe sleep video with Baltimore’s immigrant-serving Esperanza Center. Hess is working on continuing education, including a hands-on training program, for nurses.

“Cat is an amazing nurse,” says Hess of Ehrhardt, who has worked on 9 South for 28 years. “She got this whole thing started when Molly and I were newer nurses, and it has been so cool, as a Hopkins nurse, to see her original idea have such an impact. We never really even anticipated the extent of what it would become — to expand from our own unit across all the other units and over to the newborn nursery, and now out into the community, and potentially the whole hospital system. It’s just incredibly exciting to be part of it.”