Babies bed-sharing or co-sleeping with mothers. risk minimisation Guideline

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1 Babies bed-sharing or co-sleeping with mothers Definition Babies bed-sharing or co-sleeping with mothers Bed-sharing is when a baby is brought into an adult bed for feeding, cuddling or settling without the intention of sleeping. Co-sleeping is where a mother/parent and baby are asleep together. Bed-sharing is common both in hospital and at home although it is not entirely without risk. In absence of maternal sleep however there is no evidence that bedsharing has any greater risk than the mother holding or feeding her baby elsewhere. 1,7 Mothers may fall asleep while bed-sharing with their baby whether or not they intend to. There is evidence to indicate that co-sleeping is associated with a greater incidence of accident or sudden infant death (SIDS) where certain risk factors are present. To minimise risk of accidents it is recommended the safest place for a baby to sleep is a cot by the mother s bed. 5 Why To assist staff and parents to identify and address risk factors with babies and mothers bed sharing. To promote and reinforce safer bed -sharing and safe sleeping environments for new born babies. To minimise the risk of accidents associated with unintentional or uninformed co sleeping. Expected outcomes Staff identify and address risk factors for mothers and babies bed- sharing in hospital even where there is no intention of co sleeping. Mothers are informed that babies room sharing with parents for the first 6 months helps breast feeding and is protective against SIDS. 5 Staff practices within the maternity facility reinforce to parents the safety with room sharing i.e. Babies should not be left unsupervised at staff desks or other rooms. Mothers are informed and supported to benefit from bed-sharing with their babies when it is safe to do so. Risk assessment is not delegated to unqualified staff. Benefits of mother and baby bed -sharing Mothers take their babies into their bed for warmth, to breast feed provide comfort and also to settle or just to get to know their baby in comfort. To facilitate the successful implementation of the WHO/UNICEF Baby Friendly Initiative best practice standards for breastfeeding (early and uninterrupted skin to skin contact, lying down in comfort to feed and settle). Bed sharing is reported to be associated with longer and more restful infant and maternal 1, 2, 3, 7 sleep. Page 1 of 1 Version 1.4 August 2009

2 Supervision when bed sharing in hospital Level of supervision required The level of supervision required for mothers when bed-sharing will vary from time to time. For some mothers of use of cot sides may also reduce the level of supervision required. In some instances suitable family members can be asked to supervise the mother/baby to ensure the baby s safety (refer supervision by other than health professional within this guideline). Constant supervision for mothers whose clinical condition means that they cannot take any responsibility for their baby at the point in time. Frequent supervision e.g. every 5-10 minutes for mothers who can be left for short intervals only. Intermittent supervision eg minutes. - to ensure that the mother has not fallen asleep if she is bed-sharing when co-sleeping is contra-indicated, e.g. mothers who smoke, formula feeding mothers, some baby factors. - for breastfeeding mothers with none of the contra-indications listed, who have purposefully chosen to co-sleep to ensure that no dangers are present for the baby. The level of risk depends on the following factors at the time that bed sharing will occur: - clinical condition of the mother - SIDS risk factors/ other contraindications to co-sleeping (mothers who smoke, mothers who artificially feed, baby is ill or premature) - safety of the physical environment. When ever possible the risk assessment should be undertaken by midwife or medical staff in consultation with the mother/parents. Page 2 of 2 Version 1.4 August 2009

3 CLINICAL CONDITION OF THE MOTHER A constant level of supervision is required where the mother has one of the following. Maternal conditions known to create an increased risk for infants either by reducing the mothers ability to respond to her baby or increasing the chance of her falling asleep. Under the effects of a general anaesthetic. Immobile due to spinal /epidural anaesthetic. Under the influence of sedative or drugs which cause drowsiness. Ill to the point that it may affect consciousness or ability to respond normally e.g. high temperature, following large blood loss, severe hypertension. Excessively tired to the point that would affect ability to respond to the baby (after an exhausting labour this may be best determined by asking the mother if she feels at risk of falling immediately asleep). Likely to have temporary losses of consciousness e.g. unstable diabetic, unstable epileptic. Suffering any condition that would affect spatial awareness e.g. Conditions that would severely affect mobility and sensory awareness such as multiple sclerosis or paralysis, or conditions affecting spatial awareness such as blindness. Very obese (assessment to determine individual mobility, and the space available in the bed). All postnatal mothers who are given medication of a sedative nature should be reminded verbally by midwifery staff that once the sedative is taken neither bed sharing or co sleeping is appropriate. In the event the baby requires breast feeding whilst the mother is sedated a constant level of supervision will be required. If a constant level of supervision is assessed as required and unable to be provided alternative arrangements to bed sharing is required. Accidental co-sleeping on sofa or couch is however also associated with four fold increased risk to the baby. 5,6,7 Page 3 of 3 Version 1.4 August 2009

4 Bed sharing under the following conditions may increase the risk of sudden infant death (SIDS) or bed accident. An increased level of supervision is required until the baby is returned to a cot where: Mother is a smoker Smoking increases the risk of SIDS. 5, 6, 7 Mothers who fall into this category should be asked to inform staff when taking the baby into bed. Staff should provide a verbal caution that cosleeping is inappropriate and intermittent staff check undertaken to ensure the baby is returned to its cot beside its mother s bed to sleep. Artificially feeding mother Evidence suggest the artificially feeding mother can sometimes turn their backs on their 2, 3, 6 babies once fallen asleep thus increasing the risk of a sleep accident. As above, mothers in this category should be asked to inform staff when taking the baby into bed. Staff should provide a verbal reminder that co-sleeping is inappropriate and intermittent staff check undertaken to ensure the baby is returned to its cot beside its mother s bed to sleep. Baby is premature or unwell An ill or premature baby may require a supervision plan developed in consultation with lead medical staff (neonate/paediatric) before bed sharing with its mother. Bed sharing when there is minimal risk of untoward outcome will still require supervision in the hospital maternity facility. Breast feeding There is evidence to suggest that breastfeeding mothers with none of the clinical risk factors listed, whose baby is healthy and term as described, adopt a protective sleeping position facing their babies. The breastfeeding mother should be asked to inform staff when taking the baby into bed if there a likelihood that she may fall asleep. Agreement should be reached that should the mother fall asleep, either: - staff may return the baby to its cot - baby to remain sleeping in the mothers bed. Page 4 of 4 Version 1.4 August 2009

5 Planned co sleeping in the maternity facility will require: - assessment that no risk factors are present - discussion of optimal positioning (refer UNICEF illustrations) - intermittent staff checks to ensure that the baby s head remains uncovered and when not feeding, the baby is in the supine position. If a mother whose baby is at risk with co sleeping (clinical condition, or mother is artificially feeding or a smoker, or baby condition) wishes to co sleep despite recommendations to the contrary and constant supervision is not feasible. The midwife should carefully document in the medical record the information provided by the midwife and the women s decision. Document the incident on Riskman. Safety of the physical environment Adult beds are not designed with infant safety in mind. Babies can die if they get trapped or wedged in the bed or a parent lies on them. 6 When a mother is bed- sharing with her baby in the maternity facility staff should check: - baby head is uncovered (check pillows and bed linen) - baby is not able to slip under bedding - baby is not at risk of overheating not swaddled in bed - baby is not left alone in the adult bed - baby is not at the edge of the mothers bed (risk of falling out ) - bed is at its lowest level - no gaps between mattress and bed rail that would allow baby to fall through or be entrapped - call bell within mothers reach - baby is placed on its back to sleep in the cot after breast feeding is completed. Page 5 of 5 Version 1.4 August 2009

6 Handover of care When handing over care to another staff member, ensure they are aware that mother and baby are bed- sharing and the level of supervision required / agreed on individual risk assessment. Supervision by other than health professionals In some instances, suitable family members can be asked to supervise the mother /baby to ensure the baby s safety. Supervision must be by a responsible adult who is aware of role to return the baby to its own cot should the mother fall asleep. The midwife must use professional judgement to assess the family member s willingness and suitability and give basic instruction. The presence of a family member or suitable equipment does not negate the professional responsibility and accountability for safety. Informing parents of bed- sharing and safer sleeping practices During pregnancy Midwives should promote safe sleeping practices for babies and ensure all mothers have the written information offered in pregnancy in a format appropriate to their needs. Offer women the following handouts at visits around weeks of pregnancy: - Safe Sleeping -SIDS and Kids - Looking after yourself and Baby (Southern Health) Document in the medical record (MR F20) Education and information where information provided /discussed. Postnatal Parents should be reminded of the above noting and reinforcing the following dangers of bed- sharing: - Either parent is a smoker, have consumed alcohol or taken drugs which alter consciousness or cause drowsiness. - Unusually tired /exhausted where the mother feels she may fall asleep and have difficulty responding to her baby. - Risks baby over heating. Note: there is an increased danger of sleeping with a baby on a couch or arm chair (four fold increase risk) waterbed, bean bag or sagging mattress. Page 6 of 6 Version 1.4 August 2009

7 Benefits of rooming in and or bed sharing for: - settling and comforting babies - successful breast feeding in the absence of any contraindication. The safest place for a baby to sleep is a cot in the same room as the mother. 5 Prompts for reinforcing safety Posters serve visible reminders beside postnatal beds of safer bed sharing practices and when co-sleeping is contraindicated. Staff should role model positioning of babies on their back in their own cot bedside the mothers bed to sleep. If an adverse event (actual or near miss ) is associated with this CPG complete details in the health record and complete an incident report on Riskman 1. NSW Health. (2005) Babies_ safe Sleeping in Maternity Facilities. Policy directive. Sydney: Department of Health, NSW. 2. Mosko S, Richard C, McKenna J (1997).Infant arousals during mother_infant bed sharing: implications for infants sleep and SIDS research. Paediatrics 100: Mosko S, Richard C, McKenna J (1997).maternal sleep and arousals during bed sharing with infants. Sleep 201: McKenna JJ, Mosko SS, Richard CA (1997).bed-sharing promotes breast feeding. Paediatrics 100: National SIDS foundation of Australia (2006), SIDS and KIDS information statement, sleeping with a baby. 6. UNICEF (June2005) sharing a bed with your baby a guide for breast feeding mothers 7. UNICEF UK Baby Friendly Initiative. Babies sharing their mother s bed while in hospital, a sample policy, May SH Policy Patient Care ACHS Clinical Reviewer Maternity Guideline Development Group Last review date August 2009 Authoriser Maternity Executive Committee Next review date August 2012 If this is a hard copy it might not be the latest version of this document. Please see the Southern Health site for current policies, protocols and guidelines. Disclaimer These clinical practice guidelines and protocols have been developed having regard to general circumstances. It is the responsibility of every clinician to take account of both the particular circumstances of each case and the application of these guidelines. In particular, clinical management must always be responsive to the needs of the individual woman and particular circumstances of each pregnancy. These guidelines have been developed in light of information available to the authors at the time of preparation. It is the responsibility of each clinician to have regard to relevant information, research or material which may have been published or become available subsequently. Please check this site regularly for the most current version. Page 7 of 7 Version 1.4 August 2009

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