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Here's Why They Break These 5 Baby Sleep Rules In The NICU

Before a baby is even born, parents should learn (and re-learn, then learn again) best practices for safe sleep to help reduce the risk of SIDS (sudden infant death syndrome). The only caveat to these guidelines is if a baby is born early or with a serious health condition, in which case, there are some sleep rules they break in the NICU (neonatal intensive care unit) to keep babies safe and encourage growth and healing.

For the most part, medical professionals in the NICU still adhere to the general safe sleep guidelines. Carissa Stephens, RN and Medical Advisor for Healthline Media, tells Romper that most hospitals model and teach National Institute of Health (NIH) Safe-to-Sleep guidelines, endorsed by the American Academy of Pediatrics (AAP). These include, but are not limited to, making sure babies sleep on their backs on a flat surface that is "separate from anyone else (including twin siblings), and free of toys, pillows, blankets, etc."

Denise Corso-Greene, MSN, agrees, but adds that it's not cut and dry in the NICU. She tells Romper that "the hospital setting is innately different from the home environment and NICU infants still require medical care," which might mean their medical team has to break some of the general rules for safe sleep.

That still doesn't change how parents should put NICU babies to sleep once their little ones are home. "When babies are discharged, I spend a lot of time [with parents discussing] safe sleep guidelines because until close to discharge, [the infant hasn't] slept in a crib [or] only on their back," Elizabeth Brown, RNC-LRN, tells Romper.

Neonatologist Enrique Gomez, M.D., adds that in addition to teaching safe sleep, he also discourages parents of NICU babies from using home monitoring devices for things like heart rate and oxygen levels. "Research regarding home monitoring have shown that there is no decrease in the risk of SIDS when using these devices," he tells Romper. "Conversely, there is an increase in parental stress as these monitors can be triggered by normal infant movements".

The thing to remember is that these safe sleep guidelines are given to parents once their baby is healthy and thriving enough to leave the NICU, which means they are not in danger of an episode or event that could risk their life. When they're in the NICU, that's not necessarily the case, so some rules are broken... but always for very good reason.


Nothing With Baby In The Crib

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Typically, babies should not have anything dangling in or around their crib that they could accidentally wrap themselves up in. However, Dr. Gomez explains that "infants in the NICU are connected to a cardiorespiratory monitor and a pulse oximeter monitor which allows constant monitoring of apnea, bradycardia, and desaturation events." Just like adults in the hospital, wires and cords are necessary for doctors to adequately monitor certain functions to determine if there is need for intervention or observation.


No Blankets

Despite all of the blankets a mom-to-be gets at her baby shower, infants should not sleep with them in their crib because they increase the risk of SIDS. Dr. Gomez says this is another rule that may be broken for NICU babies. He explains that "nurses might use special aids or blanket rolls in order to accommodate infants to adapt for ventilators or for positioning. Also some infants with thermoregulation issues might use extra blankets for a period of time." This is only to be done in the NICU where there is 24-hour monitoring. If a baby is stable enough to be sent home, they are stable enough to sleep without blankets in their crib.


Putting Baby On Their Back To Sleep

New parents are told over and over how important it is for them to put their baby to sleep on their back. This is absolutely true for a healthy baby, but Stephens says this isn't necessarily the case for an unstable infant.

"Babies under 32 weeks gestation, under 1500 grams, or with certain medical conditions are allowed to sleep in a prone (belly) position or with positioning guides in their bed, depending on their respiratory, developmental, and medical needs," she says. "This distinction is made by defining safe sleep vs. therapeutic positioning criteria," Corso-Greene adds.


"Never Wake A Sleeping Baby" (Kind Of)

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At some point, someone came up with the rule to "never wake a sleeping baby," and a lot of times that's true.

"Infants in the NICU develop a sleep pattern that should be respected whenever possible. Non-urgent exams, blood test and any non-urgent infant's manipulation in general should be scheduled to happen around the wake time of the infant whenever possible," says Dr. Gomez. However, there are exceptions to this rule, Stephens explains, as "[some] babies are woken up to feed on a relatively strict schedule. Depending on the individual needs, this may [also] be expected to continue when they go home to ensure proper caloric intake and adequate growth and development." Plus, "some babies are [in the NICU] for hypoglycemia or high bilirubin levels and a baby who is too sleepy to eat is a warning sign," Brown points out.


Flat Surface & Crib Only

In the early days of infancy, babies should sleep in their parents' room, on a flat surface, in a bed separate from their parents (like a bassinet). They can eventually move to their own room with a crib, but the mattress should still be flat. However, in some NICUs, medical staff may bend that rule a little bit. Brown says some nurses use Mama Roos or swings to help babies sleep. She also notes that "in [some] rural hospitals... much is left to the nurse's discretion" which means they may rely on these sleep devices or have a baby with reflux sleep on an incline longer than other NICUs might. She explains that this "can set up bad habits for a baby" which may result in them "[struggling to sleep] on a flat surface at home".

Regardless of any sleep rules broken in the NICU, every expert agrees that deviation from best practices should not be continued once the baby has been discharged. Before they leave the hospital, Stephens ensures every parent is given a handout on safe sleep habits and Corso-Greene works to help parents "familiarize" themselves with their baby's care and implores them not to "be afraid to ask questions." The bottom line is that NICU professionals are trained to intervene and monitor babies in different sleep situations, and most parents are not. The safest environment for a baby who is stable and healthy enough to sleep at home is in a place where all safe sleep guidelines are followed.


Elizabeth Brown, RNC-LRN, BSN

Enrique Gomez, M.D., Neonatologist - St. Bernards Medical Center, Assistant Professor of Pediatrics - University of Kentucky

Denise Corso-Greene, MSN, RN-C (NIC), NICU Clinical Outcomes Leader, Yale New Haven Hospital

Carissa Stephens, RN, BSN, CCRN, CPN - Healthline Medical Advisor