Drawing from Safety Science to Support Safe Infant Sleep and Prevent SUID
By Tiffany Lindsey, EdD, LPC-MHSP
Dr. Tiffany Lindsey, EdD, LPC-MHSP is an Assistant Professor and Safe Systems Practitioner at the Center for Innovation in Population Health at the University of Kentucky
Since 1988, October has been recognized as Pregnancy and Infant Loss Awareness Month. It is a remembrance of our country’s littlest ones and the lasting love their parents and broader community feel for them. Sudden Unexpected Infant Death (SUID) is a leading cause of infant death in the United States. It is sometimes – maybe most times – preventable, as many of these infants die in unsafe sleep environments where they are accidentally suffocated by their caregivers or soft bedding. Yet the word “preventable” can place unjust blame and onus on parents to simply “do better or do different,” making different sleep decisions for their baby.
The true work of prevention takes a compassionate, steady, community approach. With a willingness to actively listen to caregivers, the best prevention work shares accountability for family experiences. When the American Academy of Pediatrics (AAP) launched its Back to Sleep campaign in 1994 to help reduce the incidence of SUID, the rate of deaths dropped by an incredible 60 percent. In 2012, AAP updated their guidance and launched a revised campaign, The Safe to Sleep® campaign, that advocated for the ABCDs of sleep, which stands for babies safely sleeping: Alone, on their Back, in a Crib, and with caregivers who Don’t Smoke. Cultural, racial and ethnic disparities have persisted in SUID, with non-Hispanic Black, Pacific Islanders and Native Americans being most at risk. In earnest, the AAP revised their guidance in 2022 to address and respond to these inequities.
Though all the work has been iterative and important, the “Back to Sleep” campaign yielded the most fruit, as encouraging caregivers to place babies on their backs – instead of tummies – contributed to and still informs a now far majority of babies being placed to sleep on their backs. In some contrast, the ABCDs straightforward teaching of independent, firm sleep surfaces for every nap and nighttime has proven more challenging, and evidence suggests many-to-most parents sleep with their babies at some point during their child’s infancy. Some research actually finds the rate of bedsharing increasing over time.
How, when and with whom babies sleep is a personal experience with underlying human factors.
Safety science supports a multifactorial, layered approach to SUID prevention.
Safety science is an interdisciplinary science that concerns itself with how humans naturally behave and respond to risk. With an eye towards understanding how basic human biology and normal human limitations like stress and fatigue impact decision-making, safety science gives us an evidence base for considering what humans need to achieve sustained safety amidst risk. Though much of safety science has been dedicated to understanding human performance in high-risk, safety-critical fields like healthcare, those learnings contain natural parallels to supporting people broadly to contain risk as they make safety decisions, such as the case of caregivers – often parents – with newborns. In safety science, safety is understood as a dynamic non-event, not simply the absence of harm. Beyond a binary perspective of safety or unsafety, this dynamic definition honors that:
- Safety exists in degrees and is as much a presence of protection as an absence of harm;
- Danger can be emergent and often less foreseeable in the moment as it is to those with the benefit of hindsight; and
- Layers of safeguarding and connection are crucial to sustaining safety.
With the lens of safety science, it is not hard to acknowledge caregivers fall asleep with their babies largely because it is a biologically-rewarded practice. Particularly evident between parents (most notably mothers) and their babies, skin-to-skin touch increases oxytocin – sometimes called the love hormone – and decreases cortisol – the hormone that regulates the stress response. Collectively, this hormonal experience creates a sense of calm, soothing comfort that brings regulation and wellness. And, it makes us restful.
With this acknowledgement of human factors, Safely to Their First Birthday formed in late 2022 as an open-cohort affinity group within the National Partnership for Child Safety – a quality improvement collaborative of more than 35 state, county, city and Tribal child welfare agencies. Drawing from safety science as well as improvement and implementation sciences, the Partnership has a shared goal of reducing fatalities and child maltreatment through family-strengthening systems innovation. Through sharing and collaboration, the Partnership is uniquely positioned to operationalize a person-centered, multifactorial approach to SUID prevention that advances the already robust nature of existent work.
Safely to Their First Birthday published their own guidance earlier this year, following nearly two years of work and feedback from AAP, the National Center for Fatality Review and Prevention and Social Current.
While the guidance tailors existent knowledge to the audience of home-visiting and specifically child welfare agencies, the guidance applies a new acronym – CARES – to support person-centered, listen-first, conversation starters on parent-infant sleep practices.
CARES stands for:
Caregivers: As the home visitor, speak to all individuals providing care, and ask the following questions:
Aspirations: What do you want your infant’s sleep times to look like?
Resources: Do you have everything you need to help you with sleep times?
Experiences: How have naps and night times looked so far?
Strengths: In what ways are naps and night times working well right now?
CARES conversation starters help the network of home-visiting agencies supporting parents and babies to remember to first listen to families, then offer tailored support to families through education, problem-solving and concrete resources.
All families benefit from plain language to understand the reason for the ABCDs of safe infant sleep and offers to problem-solve to help caregivers adopt safe sleep practices. But also, when caregivers describe intentions or experiences sharing a surface with their baby, harm reduction information (e.g., not falling asleep together on a soft surface like a couch, not surface-sharing while impaired) is important and simple enough to provide. Advancing the use of teaching aides like safe sleep simulation kits that use dolls with visible respiratory systems to simulate how oxygen levels change through various sleep positions is also a tactile, experiential resource with growing promise.
Beyond decisions of how and where and with whom infants sleep, SUID is prevented through a layering of protective factors. Consistent with safety science, tragic outcomes are not prevented through singular strategies but rather an intentional scaffolding of supports. Further described in Safely to Their First Birthday’s guidance, such multifactorial work best belongs within the network of public and private systems supporting families and includes:
- Evidenced and timely supports for parents with substance use problems
- Lactation and other human milk support for families
- Concrete economic supports to reduce caregiver stress and increase caregiver capacity
- Problem-solving to meet babies and caregivers’ unique needs
SUID is largely preventable, and real prevention rests with a community – not only a parent. Educating caregivers on the ABCDs of safe infant sleep is not enough, but it is a good start. Leaning in to the human factors of caregiver-infant sleep experiences, offering first to listen and destigmatize conversations, providing tailored education, and placing holistic supports around families to protect their babies are the next steps.
Dr. Tiffany Lindsey, EdD, LPC-MHSP is an Assistant Professor and Safe Systems Practitioner at the Center for Innovation in Population Health at the University of Kentucky and a member of the technical assistance team for the National Partnership for Child Safety. Her work focuses on quality improvement and system reform efforts in child welfare jurisdictions and the application of safety science to improve the safety, reliability, and effectiveness of organizations.