New guideline on safe sleep says back is best for baby

A set of recommendations aimed at creating a safe sleep environment for infants was unveiled in Toronto in February. The recommendations, contained in a clinical practice guideline titled Working with families to promote safe sleep for infants 0-12 months of age, were developed by the Registered Nurses’ Association of Ontario (RNAO).

“A lot of myths and misunderstanding about the best way to position a baby still exist, and we hope this guideline will lay the debate to rest,” says Elyse Maindonald, a nurse practitioner with the Windsor Family Health Team, who led the panel of experts that created the guideline.

Maindonald says the panel reviewed the evidence and came to the conclusion that the safest place for an infant to sleep is on their back, and alone, in a crib that meets Canadian safety standards. Maindonald says cradles and bassinets with sides that allow air flow are also considered safe places for a small infant to sleep.


RNAO’s guideline backs up previous research that strongly encourages parents to avoid using blankets, pillows and other forms of sleep aids for their baby, including positioning devices, head coverings and soft toys, which can all block an infant’s airway.

The panel conducted a comprehensive review of all the factors that can affect and shape a child’s safe sleep environment. “Given what we know about Sudden Infant Death Syndrome (SIDS), we feel confident that putting a baby to sleep on his/her back along with other important considerations, such as not smoking and the importance of breastfeeding, greatly reduces risk,” says Maindonald.


The ‘back is best’ recommendation applies throughout the first 12 months of a child’s life. The guideline also lists sleep surfaces that are not recommended for infants. They include: an adult’s bed, sofas, couches, armchairs, playpens, swings, strollers, slings and car seats.

While would-be and new parents may be tempted to choose from a myriad of baby products, the guideline recommends a firm mattress and fitted sheet are all that is needed to create the safest sleep surface for a baby. Maindonald says many people believe it is necessary to keep a sleeping baby warm with blankets and head coverings, but the evidence runs counter to that idea. “Infants over two months of age who are overheated are actually at an increased risk of SIDS,” she says.

Yolanda Guitar, a mother whose four-month-old son died of SIDS in 2004, says she hopes the guideline lends credibility to an issue that’s important but one few people want to talk about. Guitar sat on RNAO’s panel and is certified as a safe sleep expert. “We need to make sure that this subject is discussed more openly, whether it’s during prenatal classes or after a woman has given birth in hospital. This shouldn’t be a taboo topic.”

Dr. Monique Lloyd, who leads guideline development for RNAO, says she hopes the guideline will be embraced by nurses and health-care organizations alike. “We want every nurse armed with the latest evidence about how to create as safe a sleep environment as possible so they can share this information with new parents,” she says.