Registered Nurses' Association of Ontario

Extra items in the sleep environment

A safe sleep environment is free of extra items in the crib, cradle or bassinet, other than the mattress and fitted sheet.

The following extra items in the sleep environment should be noted in the assessment:

Blankets, duvets, and sleep sacks.

  • The use of a duvet has been investigated as a possible risk factor for SIDS, with contradictory results. Mitchell, Williams and Taylor and McGarvey and colleagues showed no association between the use of a duvet and SIDS after adjusting for possible confounders. In other studies, duvet use was associated with SIDS, even after adjusting for other risk factors.
  • In general, the RNAO expert panel does not recommend blankets and duvets in the sleeping area.

Pillows and pillow-like items (cushions and stuffed toys).   

  • Several case-control studies suggest an increased risk of SIDS with the use of a pillow in the crib. Additional studies did not support this finding when other factors, such as maternal smoking and low socioeconomic status, were accounted for.
  • The concern with the use of pillows and pillow-like items is the potential risk of injury by suffocation if the infant’s face becomes covered and breathing is obstructed, especially when an infant is placed in the prone sleeping position.
  • For these reasons, the RNAO expert panel recommends against the use of pillows and pillow-like items in the infant’s sleep environment.

Positioning devices or wedges.

  • These products are designed to maintain the infant’s sleeping position on the back.
  • Some manufacturers claim that these products reduce SIDS by preventing the infant from turning to the prone position. However, no studies have evaluated the effectiveness of these devices.
  • The Joint Statement on Safe Sleep recommends against the use of positioning devices. The American Academy of Pediatrics also includes a recommendation against positioning devices, concluding that there is insufficient evidence to support the claim that these devices may reduce the risk of SIDS.

Bumper pads.

  • Bumper pads were originally designed to prevent an infant’s head from getting trapped between the slats of the crib.
  • The main concern associated with the use of bumper pads is the risk of suffocation, entrapment, and strangulation.
  • Most Canadian health authorities now strongly advise against the use of bumper pads.
Women and Children
Working with Families to Promote Safe Sleep for Infants
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