Responding to research showing that in BC, First Nations and Aboriginal babies are four times more likely to die from Sudden Infant Death Syndrome (SIDS) than other babies in BC, the First Nations Health Authority (FNHA) has produced Honouring Our Babies: Safe Sleep Cards & Guide, a downloadable education toolkit to assist service providers in discussions with parents around safe sleep practices for infants. Although the exact cause or causes of SIDS are not known, there are clear safe sleep practices that reduce a baby’s risk for SIDS. The guide comments that “the reasons for higher rates of SIDS deaths in our Aboriginal communities are complex, and may include lower access to prenatal care, higher rates of smoking among pregnant women and new mothers, poverty, higher teen pregnancy rates, and lower education levels. Many of these are considered ‘risk factors’ for SIDS.”

The Facilitator’s Guide points out that, “Based on scientific research, researchers now believe that babies who die of SIDS may be born especially vulnerable to both internal and external influences. For example:

• Internal influence – some babies may be born with a brain condition;
• External influence – babies have a high sensitivity to tobacco smoke in the environment.”

Honouring Our Babies: Safe Sleep Cards & Guide is an interactive, evidence-informed tool that incorporates cultural beliefs, practices and issues specific to First Nations and Aboriginal communities. The guide includes a deck of 21 discussion cards and 7 illustrated cards that can be used by service providers to prompt and guide discussions with families about safe infant sleep, as well as a facilitator’s guide with more information, research, resources and graphics. The cards are adaptable for use in both one-on-one and group situations.

The front side of each discussion card contains a question related to safe infant sleep, as well as other holistic aspects of infant health and safety. The front side of each illustrated card shows either a safe or unsafe sleep situation, which can be used as a discussion starter with families. The back of each card (with both discussion cards and illustrated cards) contains key messages to support providers to help guide discussion and provide guidance to families.

The guide notes the importance of listening carefully and respectfully to every parent’s perspective, giving time for individuals to express themselves fully, and giving thanks for each person’s sharing and contribution. It is stressed that participants should feel comfortable in the situation, and not that they are being ‘tested’ or ‘lectured’. It also stresses that families must feel safe to turn down the offer of discussion, or call a halt to the discussion at any time: families may well have had personal experience of losing a baby to SIDS and may not yet be ready to discuss the topic.

The discussion cards require 5 – 15 minutes each of discussion time and are colour coded:

• The first 7 green cards are focused on the key practices for promoting safe infant sleep; these cover the key practices that have the greatest potential to reduce the risk of SIDS.
• The other 13 blue cards focus on a range of safe sleep situations that may be relevant to many parents and families.
• The Overview Card covers all the 7 key recommendations for safe sleep. It is recommended, if possible, to photocopy the Overview Card and give one to every family to keep.

The illustrated cards are clearly marked to show safe and unsafe practices:

• The first 3 cards (#1-3) show safe sleep practices where the parent’s decisions have helped reduce the risk of SIDS for their baby. These cards have the word ‘SAFE’ within a green circle.
• The next 3 cards (34-6) show unsafe sleep practice where there are risk factors present that increase the risk of SIDS. These cards have the word ‘UNSAFE’ within a red circle.
• The last illustrated card (#7) shows a situation where parents need to ‘problem solve’ to decide where to safely put their baby to sleep.

The seven key messages are taken from the Safe Sleep Environment Guideline for Infants 0-12 Months of Age (Perinatal Services BC 2011):

1. Place your baby on his or her back to sleep every time (at night and for naps).
2. Ensure a tobacco-free environment while pregnant and after your baby is born.
3. Place your baby to sleep in the same room as you for the first six months (on a separate sleep surface).
4. Breastfeed your baby. It helps protect against SIDS.
5. Ensure your baby does not overheat while sleeping (do not use toques or hats indoors, heavy blankets or swaddling).
6. Place your baby to sleep on a firm surface that is free of hazards. Waterbeds, pillow-top mattresses, couches, sofas, recliners and sheepskins are not firm enough for your baby to sleep safely. Loose or heavy blankets, pillows and toys should not be in your baby’s sleep area.
7. Ensure the crib, cradle, bassinet or other sleep equipment your baby sleeps ini meets the safety standards in the Crib and Cradle Regulations. Cribs made before September 1986 do not meet the standards and should not be used.

The toolkit encourages parents to make plans ahead when their baby may need to sleep outside the home. “Play pens, play yards, strollers, swings and other baby carriers aren’t designed for babies to sleep in…. Car seats are [only] designed for transporting infants safely while in a moving vehicle.” Parents are encouraged to watch their baby in any of these circumstances until they can be moved to a safe sleep surface.

Appendix 1 of the Guide gives contact information for resources for quitting smoking, quitting alcohol during pregnancy, and breastfeeding support.

Appendix 2 lists alternate safe sleep surfaces. “It is recommended that babies sleep in a crib, cradle, or bassinet that meets Canadian safety regulations. However, if families don’t have access to a crib, cradle or bassinet, alternative sleep surfaces [such as a basket, drawer, box or carton, or washtub, if in good condition] are readily available for little or no cost.” Instructions are given for how to prepare a safe sleep surface using these alternatives. Information is also given about the use of cradleboards, and how to use these in the safest manner.

Appendix 3 demonstrates why the risk of choking is reduced, by positioning the baby on his/her back to sleep.

Appendix 4 reviews crib safety recommendations.

Appendix 5 discusses the practice of swaddling babies and gives recommendations for safety if parents choose to adopt this technique.

Appendix 6 discusses the suffocation risks of soft slings and carriers, and how to minimize the danger to the baby.

Appendix 7 discusses the period of “PURPLE CRYING” between 2 weeks and 3-4 months, gives information for parents, encourages parents to reach out to friends and family for support if feeling frustrated with their baby, and stresses the danger of shaking a baby when angry or frustrated.

Appendix 8 details the dangers of wedging and entrapment when children sleep in an adult bed.

Appendix 9 discusses the dangers for babies of bed sharing in an adult bed with adults, other children, pets, and of soft pillows/blankets/duvets and other warm, heavy coverings.

The toolkit is an initiative of the Tripartite First Nations and Aboriginal Maternal and Child Health Strategy Area. The project was led by Perinatal Services BC, an agency of the Provincial Health Services Authority, as part of the Tripartite Aboriginal Safe Sleep Initiative, in response to direction from the Transformative Change Accord for First Nations Health Plan, focusing on addressing issues arising from the BC Coroner’s Office Child Death Review Report.