Transitioning Back to Sleep after the NICU

April 25, 2021

I'm katie, OTD, OTR/L, NTMTC, CNT & founder of blooming littles

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If you’ve ever been inside a NICU, you know there are a lot of beeps, dings, buzzes, and overall noise. As a Respiratory Therapist, you would think that a ventilator alarm or another staff member frantically calling my name would make me nervous. The truth is, those sounds don’t make me nervous at all. Over the 14 years that I have worked in the NICU, I’ve gained a lot of confidence in assisting the tiniest of humans to breathe. Furthermore, I know that when a baby is in trouble, I will have a team of medical experts beside me to help.

There is one noise, however, that will double my heart rate in record time and make me sweat. That sound… is the front desk phone ringing. I never know who to transfer to or what the numbers are. Inevitably, while I’m trying to figure this all out, four more callers are backing up on the other lines. You might also guess that I don’t have a team of phone answering gurus around to assist me either. It’s an all-around mess.

Needless to say, I’ve become an expert in avoiding the vicinity of the front desk. However, every once in a while, I get busted. For instance, a few months back as I was quickly making my way past the desk with my blinders on, I heard our secretary say, “Hey Mak, can you come watch the desk while I run to the lab?” Dang. Of course, no sooner than our secretary stepped on the elevator, the phone started buzzing. Cue the nervous breakdown. 

“NICU, this is Makenzie, how can I help you?”

 “Hi! I just wanted to call and check on my daughter. I’m a little confused, because she’s on her belly. I know this is a big no-no, so I wanted to call and make sure she’s okay?”

Check out: Why is my preemie sleeping on their tummy in the NICU?

Be still my ever safe sleep loving heart.

I was so excited that this mom was on top of her sleep game. And, I finally got a phone call that I could handle. 

Mom was absolutely right. The number one rule for safe sleep is “back to sleep for every sleep.” However, sleep can look different in the NICU. To assist with development, you may find your baby in positions that don’t necessarily follow safe sleep rules. With monitors and 1:1 nursing care, you can rest easy knowing your baby is safe. But, once you get home, your free membership to the Safe Sleep Club starts.

The best thing about safe sleep—it’s easy. Simply put, Alone on the Back in the Crib (ABC). The worst thing about safe sleep—it’s easy. So easy that we assume everyone just knows about it and that we don’t really need to teach it. Except we do. I urge you to not only practice safe sleep but teach it as well. By following and teaching the safe sleep guidelines below, you truly could save a life.

Back to Sleep for Every Sleep

This is hands down the most important of all the safe sleep guidelines. In my book, it is non-negotiable. Since the Back to Sleep campaign (now the Safe to Sleep campaign) started in the early 90’s, SIDS rates have decreased by over 50 percent. That information alone would make you think that there isn’t a single baby out there sleeping on their belly. However, recent studies show that it is still happening. When parents were asked why, they cited these three common misconceptions:

Misconception #1: Baby Sleeps Better On Their Belly

It’s true—most babies do sleep deeper and more sound on their belly. This is the exact reason you want them to sleep on their back. The arousals that you might witness when babies are on their back are actually protective. Along with those arousals, babies who sleep in a supine (flat on one’s back) position are better able to escape potentially hazardous situations such as rebreathing carbon dioxide and suffocating.

Misconception #2: Fear of Choking

The fear of choking is real. I get it. As a mom of a 2 and 3 year old, there isn’t a meal or snack time that I’m not on high alert. So, I can understand why parents would want to risk tummy sleeping. However, the thought that babies will choke while sleeping on their back is a common misconception. Due to the way our anatomy is structured, when babies sleep on their back it is actually easier for them to clear any milk they may have spit up than it would be if they were on their belly.

Misconception #3: Fear of Baby Getting a Flat Head

Cases of flat head syndrome certainly have increased since the Back to Sleep campaign. The good news is, you can decrease the likelihood of this by incorporating these activities into your day:

  • Use awake periods to practice tummy time—remember, “tummy to play” and “back to sleep”
  • Make it a point to decrease time spent using baby containers such as swings and carseats—the floor or a play yard are great places for your baby to move around and explore 
  • Alternate placing your baby’s head at the foot and head of the crib for each sleep—babies have a tendency to look out into the room and this will encourage them to sleep facing both directions

Chances are, if you’re here on the Blooming Littles website, you are navigating your own NICU journey. I know that as a NICU family the last thing you need is another stressor, but it’s my duty to tell you that babies born too soon are at an even higher risk for SIDS. Choosing Back to Sleep is the single most important step you can take to keep your baby safe in a world where you have so little control.

Use a Firm Sleeping Surface with No Other Soft Bedding or Objects

In my opinion this guideline is just as important as following Back to Sleep. There should only be two items in your baby’s crib:

  • A firm mattress
  • A fitted sheet

Okay, three items… Your baby belongs there too.

On the surface, this seems like a really easy guideline to follow. However, the marketing of sleep products and pictures of “pretty” nurseries can easily skew our judgement. Please remember: just because it is sold doesn’t mean it is safe

A few specific products come to mind, the first being mesh bumpers. I think most everyone agrees that the big poofy, luxurious, crib bumpers are a big N-O. But the mesh bumpers tend to have less of a scare factor, maybe it’s because they are marketed as “breathable”. Unfortunately, that does not put them in the category of safe. They can become untied or bunched up and turn into a suffocation risk.

The second product that comes to my mind are the baby loungers. I’m seeing more and more baby loungers in the crib. Although they are marketed as a place to play and change diapers, parents are using them for sleep. It’s essentially like putting a big pillow in your baby’s crib—best to stay away from them. Your floor or play yard is the perfect place to play and change diapers.

There are so many products out there, and it’s hard to tell which ones have been tested for safety and which ones haven’t. If you use your best judgement, you’ll be just fine. Here’s a quick tip: if you are unsure about a product, you can check out some other countries’ regulations, such as Canada . Did you know they have a tendency to hold products to a higher standard and are quicker to ban potentially unsafe ones than we are here in the United States??!

Dress Your Baby for Sleep

When dressing your baby for sleep you want to make sure you are:

  • Avoiding too many layers—babies can easily overheat. A good rule of thumb is one more layer than you would be comfortable in for the temperature of the room
  • Not using head coverings such as hats or hoods
  • Not using pacifiers with strings, clips, or buddies attached
  • Using only tightly fitted pajamas
  • Swaddles are okay, but once baby begins to roll and become more mobile it’s time to transition to wearable blankets—around 8 weeks

Other Recommendations

Along with the above recommendations, the American Academy of Pediatrics also promotes use of a pacifier, breastfeeding, and room sharing but not bed sharing. I think it is great if you can follow these guidelines as well, but I personally do not deem them as non-negotiable like I do the back to sleep and empty crib rules. Let’s be honest—not every baby likes a pacifier and breastfeeding doesn’t work out for everyone. As far as room sharing, in my opinion, that is a more personal choice. I was so afraid that I would fall asleep while feeding my daughters that I chose not to do this. As always, do what is best for you and your family. And give yourself some grace—this parenting stuff is hard.

Be sure to check out my safe sleep and safe nursery checklists here. One day, probably sooner than you think, you’ll be transitioning to a big kid bed.

Stay safe and talk soon!


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