Sleep is crucial for your baby’s growth and for your own well-being as a caregiver. If your baby spent time in a neonatal intensive care unit (NICU) or has special medical needs, you may have concerns, such as if it's safe for your baby to sleep on their back, if newborns can sleep with a pacifier or for how long your baby should sleep in sleep sacks. Our neonatal experts can help calm your worries. You may have some extra concerns if your baby has a medical condition, but you can still use the same safe sleep tips that are recommended for all babies. This guide outlines safe sleep practices for infants, aligned with the American Academy of Pediatrics recommendations.

Follow updated sleep guidelines for babies

The same infant safe sleep practices that keep all babies safe and protect against sudden infant death syndrome (SIDS) apply to babies with medical conditions. Make sure you follow updated sleep guidelines from the American Academy of Pediatrics (AAP), which include the following tips:

• Place your babies to sleep on their back. If your babies can roll over from their back position, then they can remain there for sleep, but they should initially always be placed to sleep on their backs. 
• Your baby should sleep on their own in a bassinet or crib.
• Make sure your baby’s bassinet or crib has a firm mattress with a fitted sheet.
• Don’t have other objects like blankets, pillows or extra sheets in the crib.
• Your baby can have a pacifier during sleep if it’s not clipped to clothes or around their neck.
• Do not put a pacifier back in a baby’s mouth once they’ve fallen asleep.
• Try to avoid alcohol or drug use when you are getting used to sleep training your baby. 

Infants are at an increased risk for SIDS when:

• Their nose or mouth is covered
• They’re covered with too many blankets
• Their room is too hot, potentially causing hyperthermia (abnormally high body temperature)
• They have loose items in their bassinet or crib
• They sleep on their stomach or side
• They share a sleep surface with their parents (called bed-sharing)
• They are near any smoke

You can swaddle your baby with a light blanket or sleep sack if the blanket does not move above their shoulders. The best sleeping position for an infant with acid reflux is always on their back.

Many new caregivers wonder if it is safe for their infant to be in a sleep sack once they start to roll over. Generally, once your baby can roll over on their own, you should not swaddle them or put them in a sack. Place them on their back when they go to bed. If they move to a different sleep position, it’s OK to leave them as long as their airway is open.

If your baby falls asleep outside of their bassinet or crib, such as in a car seat, try to move them back to their firm mattress as soon as you can. Babies in the NICU often have more trouble feeding and may seek comfort. It is natural for caregivers to want to give them attention throughout the night. Resist the urge to let them sleep in your bed. Instead, your baby can sleep in a bassinet next to your bed. Room-sharing (not bed-sharing) allows you to still give your infant attention without the risk of SIDS.

Safe sleep for babies with medical equipment

Babies who go home with oxygen, a tracheostomy tube, a gastrostomy tube (g-tube), a monitor or other medical equipment may need some extra care for sleeping. The good news is that these babies are used to sleeping with medical equipment in the NICU, so it typically doesn’t cause discomfort.

The main concern for babies sleeping while attached to medical equipment is that they could get wrapped in cords or tubes. Make sure any cords or tubes take the most direct path from your baby out of their bassinet or crib to wherever they need to be connected. Try your best to keep any cords away from your baby’s hands. If you’re swaddling your baby, allow cords to come out of the bottom of the swaddle and avoid your baby’s face or hands.

If you have devices that sit outside your baby’s sleeping area, it is important to get the necessary equipment to safely secure these devices outside of the sleep area before you leave the NICU. For example, if your baby has a g-tube, you should have an IV stand or other piece of equipment to safely secure the feeding pump outside of your baby’s crib or bassinet. Those items shouldn’t sit in your baby’s sleeping area.

Your baby’s providers will arrange the necessary equipment for your family. Our experts do not recommend getting any equipment or devices that have not been directly provided by your baby’s care team.

Don’t bring the NICU home

When your baby is in the NICU, they may not be medically ready to be positioned flat on their backs without any positioning devices because of their need for breathing support or other medical devices. Because of this, your care team may use positioning aids or place the baby in positions that are not recommended for home. When your baby is medically ready, your care team will transition your baby to a safe sleep position (on their backs, with head of the bed flat) and environment (no unsafe objects in the sleep area).

Your baby will be medically stable and ready to sleep safely on their back without any positioning aids or other objects in the sleep area.

In that same vein, many families ask if their baby should sleep on a slight incline if they suffer from acid reflux. Research shows that this does not provide any relief from reflux, and the additional padding needed to create an incline could cause breathing problems since babies are not able to keep their heads positioned straight to protect their breathing tube. The best acid reflux sleep positioning is directly on the back.

Maintain safe sleep timelines

We recommend that your baby sleep in a bassinet or crib in your room, but not in your bed, until they are about 1 year old. This timeline remains true for babies born prematurely or with medical conditions. Co-sleepers are a great option. They provide a separate sleep surface for your infant while still keeping them close.

The exception is for babies who have breathing conditions and are on a ventilator to help them breathe while sleeping. These babies need 24/7 monitoring. Parents often take shifts or hire home nurses to ensure monitoring around the clock. In this case, it can be better for everyone’s sleep and well-being if your baby sleeps in their own room.

Finally, it’s important to remember that getting any newborn to sleep safely on a schedule that also allows you to sleep is challenging. And it can be extra challenging for a baby with a medical condition. Remember that this is an adjustment period and give yourself some grace. Whether or not your child sleeps when you want is not a reflection of your ability as a parent. Implementing safe sleep practices for infants at home can keep them just as safe as they were in the NICU.

Still have some questions? Check out our NICU safe sleep video below.