Front Cover:
Back to Sleep: Each week, 3 babies die of SIDS in Canada. According to the latest research, there are things you can do to reduce the risk of Sudden Infant Death Syndrome (SIDS): Call 1-900-END-SIDS.

Suggested New Titles:

1. Back to Sleep: Creating a Safe Sleep Environment for Your Baby
2. Back to Sleep: Safe Sleep for Babies
3. Back to Sleep: Safe Sleep Tips for Your Baby

Comments received prior to the roundtable: Include message: “Share this information with everyone who cares for your baby”

Comments received prior to the roundtable: Include message: “Share this information with everyone who cares for your baby”

• The reference to three babies dying of SIDS per week is outdated.
• Some parents have indicated that they are turned off by this statistic and/or feel SIDS cannot happen to them.
• SIDS is no longer the leading cause of postneonatal death for infants (rather, it is congenital anomalies). However, as SIDS rates have fallen, there has been an increase in the proportion ofother Sudden Unexplained Deaths in Infants (SUDI) cases.
• The differentiation between SIDS and other causes of sudden death in infancy can be very difficult. What may be SIDS in one jurisdiction is asphyxiation in another.
• People are aware of SIDS, but don't know what SUDI relates to. Should not try to distinguish between the two because the definitions are changing and are overlapping.
• Consider not mentioning SIDS at all on the front cover and using a title such as “Safe Sleep for Babies” or “Back to Sleep: Safe Sleep for Babies” instead.
• The focus of the brochure needs to be clear – safe sleep practices for infants – and determine the terminology to be usedtaking into consideration how parents will interpret the information.
• Consider expanding the brochure beyond 12 months of age up to 2 years old to ensure that parents don't relax their safe sleep habits as a result of the definition of SIDS
• A more general statement that does not refer to statistics should be used on the cover. CFSID would like to see the word “safe” or “safety” on the front cover.
• Focus testing needs to be done to ensure that the messages effectively reach the intended audience.
• Limit the brochure to three or four key messages.
• Could also congratulate parents for the safe practices they're already using (room-sharing, cuddling, etc.)
• Support to include a message to share information with everyone who cares for your baby given the SIDS risk that exists in non-parental child care.

Sleeping Position

SIDS is less common in babies who sleep on their back.
Put your baby to sleep on his or her back on a firm flat surface. You do not need anything special to do this. Babies who sleep on their back are not more likely to choke. Some babies have a medical problem that means they must sleep on their tummy. Ask your doctor which position is best for your child.

Older babies may be able to turn on their own from their back to their tummy. It is not necessary to force babies to sleep on their back when they are able to turn from their back to their tummy on their own.

• It was agreed that the following sentence should be deleted: “Some babies have a medical problem that means they must sleep on their tummy.”
• Suggestion to change first sentence to “Babies who sleep on their backs have a decreased risk for SIDS”.
• Re-enforce that back is best.
• Sentence on choking probably useful.

Positional Plagiocephaly (flat spots)

When the baby is awake and being watched, some "tummy time" is necessary for the baby's development. This will also avoid temporary flat spots which sometimes develop on the back of their head from lying on their back.

Comments received prior to the roundtable: information outdated – include more preventative info; increase “some” tummy time to “several” times a day; include info on changing the direction that your baby lies in the crib from one week to the next; include message “avoid too much time in car seats, carriers, and bouncers while the infant is awake”; include message “lots of "cuddle time" with the baby by holding him or her upright over one shoulder often during the day when awake.”

• Some parents are no longer placing infants on their backs to sleep because they are concerned about the esthetics of flat spots.
• Parents are overly concerned about flat spots.
• Flat spots are occurring more now because of infants spending extended periods of time in car seats and carriers when it is not sleep time.
• This should be mentioned briefly in the brochure by making reference to another resource online for more information.
• “Tummy time” can be emphasized to reduce the risk of flat spots and encourage normal development (acquiring strength in the neck muscles).
• Flat spots are reversible.
• There is no evidence on the relationship between tummy time and SIDS.
• Tummy time is helping to reduce plagiocephaly, but there is no evidence that it reduces any risk of sudden death.
• It is important to be clear about how much tummy time, when and how.
• Body image is an issue with parents so they will listen to these messages.

Baby Bedding

Avoid soft mattresses, fluffy pillows, comforters, stuffed toys and bumper pads in the baby's crib as these could prevent proper air circulation around your baby's face. Plastics, such as the manufacturer's mattress wrapping, may also prevent air circulation, and should be removed to reduce the risk of SIDS and also suffocation.

Comments received prior to the roundtable: replace “fluffy” pillows with “avoid all pillows”;
add to the list of items to avoid: sleep positioners, duvets, quilts, and lambskins; crib mattresses should be firm and tight-fitting;
 

• Include some detail as to the types of cribs to look for.
• Include info that cribs made before 09/1986 or without a label are unsafe to use – check with Health Canada if uncertain.
• There may not be enough room in the parents' bedroom for a full-sized crib – offer alternatives.
• Low-income groups are less likely to have access to a crib.
• Need to address the issue of bassinet safety standards since this is probably the most common sleep surface for the 1st month of life. Health Canada is in the process of establishing requirements for bassinets under the Hazardous Products Act (HPA) Cribs & Cradles Regulations. Link to consultation document: http://www.hc-sc.gc.ca/cps-spc/advisories-avis/info-ind/crib_cradle-reg-lit_berceau-eng.php
• Avoid adult pillows and comforters. Pillows should never be used around infants in any circumstances.
• Do not roll towels or blankets to keep baby in place. Do not use positioners to keep baby on back.
• Include a new section on “Unsafe Sleeping Environment”.
• Suggested that the sentence on plastics be removed.

Bedsharing

Bedsharing is a common practice for many families. However, the risk of SIDS will not necessarily be reduced if your baby sleeps in the same bed as a parent, brother or sister. In fact, the risk of SIDS increases if the baby sleeps with a person who smokes. Your baby is also at risk if the person has been drinking alcohol or taking drugs that may make them less able to respond to the baby.

• A crib is the safest place for a baby to sleep.
• The Canadian Paediatric Society has recommended against all types of bed sharing.
• Unclear to the public whether bed sharing is a risk factor on its own or only when it is coupled with smoking.
• Recommendations about bed sharing and smoking are evidence-based – some felt others are based more on common sense. However, one participant disagreed, stating that bed sharing with young infants is a risk, even without smoking (odds ratio 2 to 2.5).
• A harm reduction approach is used in smoking, so why not for bed sharing, since it is supported by the evidence.
• No adult bed is a safe place for an infant to sleep, so there should be no mention of “how to bedshare safely”.
• People bedshare because they feel that it is the safest place for an infant to sleep, because they're breastfeeding or feel they can provide more supervision of the baby if they're in the same bed.

A Smoke- and Drug-Free Environment

Create a smoke- and drug-free environment for your baby before and after birth.

Avoid using drugs such as alcohol, marijuana, crack, cocaine and heroin if you are pregnant, planning to become pregnant or breastfeeding. No one should smoke near your baby, not only for your baby's health, but also to reduce the risk of SIDS.

• Smoking and drug use should be treated separately.
• Substances (drugs and alcohol) that decreases vigilance should be covered in “safe sleeping environment” section.
• Do not enumerate drugs because some will be missed.
• A smoke-free environment needs to be one of the key messages.
• Smoking during pregnancy is the most important risk factor.
• The message should address pre-natal and post-natal smoking, as well as secondhand smoke from people other than the mother.
• Smoking during pregnancy carries the highest risk, but there is a small risk if the father smokes pre-natally.
• The risk of SIDS is increased by continuing to smoke, especially while in bed with an infant.
• There are programs in Canada to assist expectant mothers and mothers who want to quit smoking. (See www.pregnets.org.)
• Mothers who are unable to quit smoking pre-natally are more likely to be depressed post-natally. Even for those who have quit, given that tobacco is used to self-medicate for depression, this puts women with postpartum depression at risk of relapsing.
• Disadvantaged populations have had a higher risk of SIDS, in part because low income groups are more likely to smoke.
• Reference was made to the information released by Australia – SIDS and Kids.
• Fewer studies show that there is an increased risk of SIDS as a result of recreational drug use.
• There may be a connection between drug use during pregnancy and SIDS.

Dressing Baby For Sleep
Keep your baby warm — not hot.

Babies need to be warm, but they should not become too hot. If the room temperature is right for you, it's right for the baby, too. To check if your baby is too hot, place your hand on the back of his or her neck. Your baby should not be sweating. Use lightweight blankets which you can add or take away according to the room temperature.

 Comments received prior to the roundtable: add message avoid overheating

• The message on overheating should be removed as it was an issue for infants placed on their stomachs to sleep.
• Being too warm or overheating are risk factors for SIDS in babies sleeping on their stomach. This text should be removed.
• See Mitchell E, Arch. Dis. Child. 2007;92;155-159.

Breastfeeding

Breastfeeding is good for your baby.

Breastfeeding is the best way to feed your baby. It has many benefits and may give some protection against SIDS.

• New research shows that there is some evidence that there is a protective effect of breastfeeding with respect to SIDS. Newer studies may change some of the balance of the weight of evidence on this.
• However, inclusion of this reference to breastfeeding was questioned as there may be confounding factors as to why the rate of SIDS is lower for breastfed babies, e.g., most mothers who breastfeed are not smokers.
• Some felt a breastfeeding message was inappropriate, while others thought that it is a simple, general message that fits.
• Could go under a section on good practices.

Back Cover

It is really important that parents who have lost a child due to SIDS should not blame themselves. Until the cause or causes of SIDS are found, research can only show us how to reduce the risks. For more information on SIDS call 1-800-END-SIDS or visit www.phac-aspc.gc.ca

• Suggested new wording: “New research is allowing us, more and more, to find the specific causes for SIDS, and how to reduce the risk.”
• Since both SIDS and other causes of death (unintentional accidents/injury) will be addressed, new wording is required.

1) Pacifiers (dummies or soothers)

•  There are issues surrounding information available on the connection between pacifiers and SIDS.
• Rather than actively promoting pacifier use, it would suffice to say that if your baby has started to use a pacifier, continue to offer it at sleep time.
• The issue of pacifiers could be addressed in a FAQ section.

2) Room Sharing

• Room size is an issue as many bedrooms do not have room for an adult bed and full-sized crib.
• The evidence is not conclusive as to why room sharing is a prevention strategy for sudden death.
• There is no known risk for room sharing.
• Could be re-enforced as a good practice.  

3) Unsafe Sleeping Products (being left to sleep for extended periods of time in products, such as car seats, infant swings, etc, that keep infants in an upright position)

• Emphasize product safety information (bassinets, playpens, car seats, bedding, etc.)
• Bassinet use very common the first month of life.
• Just because a product is sold does not make it safe.
• Competing with consumerism.
• Illustrate what a safe sleeping environment looks like.

4) Unsafe Sleeping Surfaces (water bed, air mattress, sofa, futon, beanbag, memory foam)

• A wide range of unsafe sleep surfaces should be addressed.
• It is an increasingly common practice for an infant to be placed to sleep on the chest of a parent who is lying on a couch.
• Should be dealt with in a separate section on safe sleeping environment.

5) General Comments

• The focus should be on sudden death in infants (not SIDS or SUD). The CFSID has received feedback that parents didn't read the brochure because they thought that SIDS couldn't happen to their baby. They said that they would have read it if they'd known it was about the safety of their baby.
• It would be best to deal with SUDI and SIDS together, and to focus on safe sleep practices to reduce the risk of both SIDS and unintentional accidents (e.g., suffocation from overlay) from occurring during sleep time.
• Consider limiting brochure to 3 points to decrease the risk of sudden deaths: no smoking during pregnancy, back to sleep, and safe sleeping environment. These 3 points will cover >90% of deaths.
• The safest sleep position is on the baby's back – babies coming home from the hospital should be placed to sleep on their backs (many infants are place on their stomach while in the hospital and parents repeat this observed behaviour).
• Look at the new trend of “wrapping” or swaddling babies as parents tend to believe that it leads to improved sleep.
• It is important to stage the information in the brochure pre-natally, immediately after birth and post-natally.
• A large proportion of the population does not speak English or French, so the illustrations will have to be very clear about the risks.
• The brochure should be simple, but not so simple as to leave out important messages.
• The brochure should have lots of visual interest, with carefully chosen images and graphics.
• The brochure should meet the needs of those with low literacy levels.
• The revised brochure could have the key messages on pull-up tabs that reveal additional information underneath.
• Messages need to be tailored so that they can be embraced by special populations with different cultures, such as Aboriginal peoples.
• The rate of SIDS is going down much faster in the non-Aboriginal population – are there Aboriginal issues surrounding SIDS that should be taken into account in the brochure?
• Some of the issues with Aboriginal populations may be the use of slings, hammocks and swaddling devices.
• Distribution mechanisms should be reviewed to allow for increased dissemination, especially to Aboriginal peoples.
• The advice given should not be controversial.
• Modifiable risk factors should be the focus.
• If there is no biological evidence base, it is only ethical to provide advice if it definitely will not cause harm.
• There should be a teaching guide on safe sleep for health care professionals.
• Consider developing a door hanger with key safe sleep messages.
• The (U.S.) National Institute of Health (NIH) has messages on SIDS for parents, health care providers, caregivers and a Question and Answer fact sheet through its Back to Sleep Campaign – an initiative of the National Institute of Child Health and Human Development (NICHD). (See http://www.nichd.nih.gov/news/releases/sids_risk.cfm)
• The NICHD joined forces in 2003 with three national African American Women's organizations in a year-long program to reduce the risk of SIDS among African American infants. (See http://www.nichd.nih.gov/news/releases/sids_risk.cfm and http://www.nichd.nih.gov/publications/pubs/upload/safe_sleep_aa1.pdf - revised 2005.)
• SIDS information is based on old research methods.