Safe sleeping and Sudden Unexpected Death in Infancy (SUDI)

Ko te ahurei o te pēpi arahia o tātou mahi

 Let the uniqueness of the baby guide our work

Updates made to this guidance

This guidance has been significantly updated to include a practice lens and the most recent evidence and data.

Why we need to be aware of SUDI

SUDI is the leading cause of preventable death for pēpi aged 28 days to 1 year, with most occurring between 2 months and 4 months of age. Between 60 and 70 pēpi died unexpectedly each year between 2018 and 2020 in Aotearoa New Zealand.

Sudden Unexpected Death in Infancy: An analysis of coronial SUDI Liaison Reports from Sept 2018 to June 2020 with subsequent recommendations | Ministry of Health

Most SUDI is explainable. Common causes are suffocation by bedding or accidental smothering by an adult or tamaiti who is co-sleeping with pēpi. Many SUDI can be prevented and a safe sleeping environment can help.  

We have an opportunity to support whānau and families by promoting education about the risks of SUDI and the measures whānau and families can take to prevent tragedy and protect their whakapapa. While we can’t guarantee preventive measures will stop SUDI from occurring, we can help educate and advocate for pēpi.

Hāpai – SUDI Prevention Coordination Service

Change for our children

How we can help

We need to understand what SUDI is, and its key risk and prevention factors.

Sites can organise training sessions with their local health SUDI specialist.

SUDI | Health Navigator NZ

Reports of concern may not directly describe SUDI risk factors, but we should seek information to understand if we need to advocate for and assist the whānau or family to minimise risk factors.  

We celebrate the uniqueness of every pēpi and the taonga (gift) they represent for their whānau or family by spending time with whānau or family to promote the protection of pēpi.

Risk factors for SUDI

Pēpi are potentially more vulnerable to SUDI when certain risk factors are present.

Some risk factors are unavoidable:

• born before 36 weeks
• low birth weight (under 2500 grams or 5.5 pounds)
• health issues
• born to a young mother
• male.

Environmental risk factors that can be managed are:

• co-sleeping with adults, especially if they have been using drugs or alcohol
• co-sleeping with siblings, cousins or extended whānau or family
• unsafe sleeping situations – for example, an unsafe position (see below), loose covers or soft bedding or lots of stuffed toys in the cot, which pēpi could slip underneath.

Further risk factors include:

• born to a mother who smoked during pregnancy
• exposed to drugs or alcohol during pregnancy
• born to a mother who received late or no prenatal care.

Strengthening our response to unborn and newborn pēpi

Social risk factors include:

• homelessness or transience
• inadequate (overcrowded) or emergency housing
• poverty and financial insecurity
• addictions or health issues that impair parenting
• smoking
• parental or caregiver exhaustion – extreme tiredness impacts the ability of parents or caregivers to make rational and safe sleep decisions for their pēpi
• caring for an unwell or unsettled infant, which can increase the risk of co-sleeping because parents want to monitor or support their pēpi
• swaddling.

If we identify risk factors

If we identify any SUDI risk factors, there are ways we can help. We can:

• take a sensitive approach with whānau and families – we acknowledge the mana of the parent, the partner and their whānau or family along with the mana of the unborn or newborn pēpi, and we are aware that anxiety about SUDI or fear of judgement might stop parents and whānau or family from asking questions or being open
• consider if we’re the right person to talk with the parents, whānau or fammily – we can seek out appropriate cultural advice or refer to a health professional and take a team approach
• share the known facts and risk factors to help them understand why we raise SUDI with them
• help them to focus on the oranga (wellbeing) of their unborn pēpi and of the whole whānau or family and to recognise if they need extra support, care and attention
  Staff resource: Te Ao Māori principles of oranga
• recognise the challenges of addiction, poverty, violence and homelessness and the impact of trauma, and consider the capacity of the parents and their whānau or family to minimise or address any risks
• compliment the parents, whānau or family when we see prevention measures in action
• explore the parents’ and whānau or family’s knowledge about SUDI – identify if they are aware of ways they can minimise the risks and highlight the ways to reduce risks
• encourage them to make a plan with their supports about where pēpi will sleep when they are feeling exhausted or pēpi is unwell or irritable
• advocate for them with the appropriate services if financial issues are impacting on their ability to provide pēpi with their own safe sleeping space – a danger time for pēpi is when their normal bed is not available so, if pēpi is moving between homes or visiting, explore options to maintain a safe sleeping space for pēpi, such as a pēpi-pod® or wahakura, which are portable and able to be in the same bed as the parents or caregiver
• take an educational, inquiry approach if there are smokers around pēpi, exploring what people can do to minimise exposing pēpi to second-hand smoke
  Stop smoking services | Health Promotion Agency Smokefree
• check that our communication is effective, and that people with a disability or those with English as a second language understand what supports are available. It may not be a one-off conversation.

We record our analysis and our understanding of how the whānau or family are responding to the care needs of their pēpi.

Māori and Pacific have higher rates of co-sleeping, and caring for pēpi can be a shared responsibility with extended whānau or family. Consider how to share SUDI prevention information with everyone in the whānau or family – is there another person who might understand the cultural context better? Consider holding a hui to identify the needs and supports and to allow the whānau or family and caregivers to make informed decisions about the care of their pēpi.
Working with Pacific peoples: Va'aifetū
Working with Māori: Te Toka Tūmoana

Keeping pēpi safe during sleep

Avoiding too many layers will also help keep pēpi from overheating, as will using clothing and bedding made from natural fibres. The room temperature should be around 20°C. An easy way to check their temperature is by feeling the back of their neck or their tummy (under the clothes) – they should feel warm, but not hot or cold.

The following preventable measures are recommended for all pēpi and are required for pēpi in care:

• have their own bed
• sleep on their back with their face up
• sleep with their face clear.

Pēpi-Pod® sleep space programme

A safe bed for pēpi has:

• a firm and flat mattress to keep their airways open
• no gaps between the bed frame and the mattress that could trap or wedge pēpi
• cot bars that are around 50mm apart (the gap should be no more than 95mm).

Pēpi should also have their feet close to the end of the bed so they can’t burrow under the blankets.

Avoid soft or loose bedding, soft mattresses, pillows, sheepskins, bumper pads, and stuffed toys, as well as adult beds, couches, chairs, beanbags and waterbeds, and any position where their head can drop forward and block their airway – for this reason, pēpi shouldn’t be left to sleep in car seats. Also avoid amber beads and ‘teething’ necklaces while pēpi is sleeping.

Pēpi should be put back in their own bed after feeding.

Face up

• Pēpi should sleep face up (on their back). This will keep their airways clear.
• A built-in alarm reminds them to breathe, and strong gag and swallow reflexes protect their airway if they vomit.
• A doctor may recommend a different sleep position for pēpi with special needs.

Face clear

Keeping their face clear helps pēpi breathe freely and not get too hot.

Other ways to help protect pēpi from SUDI

Homes and cars should be smoke free. All smoking harms pēpi (including during pregnancy). Smoking takes oxygen and weakens vital systems as pēpi develop. When born, these pēpi need extra protection.

Policy: Smoking and vaping