How Two NICU Teams Worked to Make Sleep Safer for Babies Before and After Going Home

A plain-language article for families on two recent hospital projects, one in Houston and one in Chicago, on how a NICU can model safe sleep and help families keep their baby safe at home

Two hospital teams recently tested ways to make sleep safer for babies who spend time in a neonatal intensive care unit (NICU). In Houston, changing the beds, the daily routines and the reminders raised the average share of the five safe-sleep habits being followed from 58% to 91%. In Chicago, extra teaching for families of Black babies kept an already high rate of safe sleep (about 96%) steady, and fewer parents said their baby never slept alone in a crib. Neither study tracked baby deaths, so they show good steps rather than proof of lives saved.

When a baby comes home from the NICU, the first night in a crib at home can feel frightening. Parents have spent weeks watching monitors and nurses, and suddenly the machines are gone. Safe sleep is one of the most important ways families can protect a baby after discharge, and it is something every family can learn. This article explains what two hospital teams did to help, and what you can take from their work.

Why safe sleep matters, and how we learned it

Doctors use the term "sudden unexpected infant death," or SUID, for the sudden death of a baby that could not have been predicted. Some of these deaths have a clear cause, such as suffocation, and others stay unexplained. Many happen when a baby is sleeping in an unsafe place, for example sharing a bed with an adult, or lying near pillows, blankets or soft toys. A national campaign called "Back to Sleep," launched in the 1990s, taught families to place babies on their backs, and researchers report that these deaths have fallen by more than half since then [1]. In 2021 they were still the third leading cause of death in US babies under one year old [1], and being born early adds to the risk [2].

The American Academy of Pediatrics, the main US group of children's doctors, advises that babies sleep on their back, alone, on a firm, flat surface with nothing else in the crib, and that they not be loosely swaddled [3]. Staff are asked to follow these rules themselves so that parents see them in action. Sleeping on the stomach and sharing a sleep surface are major contributors to these deaths [4].

Babies in the NICU make this more complicated. Very small babies often need breathing support and may be placed on their stomachs or propped up to help them breathe or grow. The AAP therefore advises that babies move gradually to safe sleep before they go home [5]. Earlier hospital teams have shown that units can improve their safe-sleep habits [6] [7] [8], and that teaching parents while they are still in the hospital may help them keep up safe sleep at home [9]. But one project that checked on families after discharge found no clear improvement, and fewer than half of the families answered the survey [10]. There is also a fairness problem. Black babies die of these causes more often than other babies, and their rates have fallen more slowly [11]. The two projects below tried to address these gaps.

The Houston project: change the bed, not just the message

The first team worked at a county hospital in Houston, Texas, that serves many families without health insurance and delivers more than 5,000 babies a year [2]. Staff noticed that many babies were not sleeping safely, even though the hospital had an old policy about safe sleep after 34 weeks. The policy lived only in a single computer order that often expired before it mattered.

The team wrote five simple standards for babies who were at least 32 weeks along (counting from the mother's last period) and needed little breathing help: on the back, alone in the crib, bed flat, tight swaddle only, and face uncovered. Doctors in specialty training visited bedsides at random times, day and night, to check what was happening. They looked at 575 sleep moments in all.

At the start, on average only 58% of the five safe-sleep habits were being followed. The most common problems were a raised head of the bed and extra items in the crib, which together caused about six in ten failures. Many nurses believed that raising the head of the bed helped with reflux, when milk comes back up from the stomach. The team did not simply tell people to stop. They added a daily reminder to the doctors' notes, held a teaching session that reached more than eight in ten nurses, swapped tilting cribs for plastic bassinets that are hard to tilt, and posted bedside signs in English and Spanish. By the end, on average 91% were followed. The share of babies who met every single standard climbed from 9% to 56%. A flat bed went from 51% to 86%, and an empty crib from 47% to 80%.

The Chicago project: teaching families in a way that fits their lives

The second team worked at the University of Illinois Hospital in Chicago, where about two-thirds of the babies in the NICU are Black or African American [1]. In their county, Black babies died of these causes at 14 times the rate of white babies in 2020 and 2021. The team set out to improve teaching for mothers of Black babies.

They created a one-page handout called "Alone-Back-Crib," which used local numbers and plain words such as suffocation instead of medical terms. They also made short videos in English and Spanish, trained nurses and doctors, and gave families a children's book about safe sleep. About four weeks after going home, mothers were asked how often they followed five safe-sleep habits.

Overall safe sleep was already very high at 96% before the project and was 97% afterward, which is not a meaningful change. But one answer did shift: mothers who said their baby "never" slept alone in a crib fell from about 11 in 100 to about 4 in 100. Parents said the handout was easy to understand and helped them feel more aware. Most did not feel extra stress or worry about putting safe sleep into practice at home.

What these projects can and cannot tell us

These were improvement projects in single hospitals, not experiments with a comparison group, so we cannot be sure that the changes caused the results. The Houston team checked what staff did in the hospital, not what families did later or whether any baby was harmed. The Chicago team relied on what mothers reported, which can be generous, and the mothers in the two periods were reached in different ways. Dips in the Chicago results coincided with two nursing strikes, though we cannot say the strikes caused them. Importantly, neither project could count baby deaths, because these events are thankfully rare and hard to measure in one hospital.

What this means for families

The practical lessons are encouraging. If your baby is in the NICU, ask when the team plans to start safe sleep and why. Once your baby is ready, the safest sleep setup is simple: on the back, alone, in a flat crib or bassinet with nothing else in it. You may notice your nurses doing this and that is on purpose. If your baby has special needs, such as reflux or breathing support, talk with the team before discharge, because some advice differs in the hospital, where monitors watch your baby, and at home, where they do not.

It can help to hear messages in concrete words. In Chicago, parents who received the handout in person said it was easy to understand and made them more aware of these risks. The Chicago authors point to earlier work showing that suffocation-focused messages cut down the use of soft bedding among African American parents [12], and that advice from a health professional improves how closely families follow safe-sleep practices [13]. If anything about the advice is confusing or does not fit your home, ask your care team, who can help you find a safe set-up that works for you.

What researchers are working on next

The Chicago team calls for lasting efforts, community involvement, staff training on bias and on health inequality, and changes to how care is organised. They note that one NICU found staff became more aware of their own misconceptions after such training [14], and cite research suggesting that Black newborns had lower death rates when cared for by Black physicians [15]. It would also help if future projects followed babies after discharge to see whether safe sleep in the hospital leads to safe sleep at home, ideally across many hospitals, so that effects on deaths could someday be measured. For now, the clearest message is one every NICU family can use: back, alone, crib, every sleep.

References

  1. Farouk F, Pham A, Pillers DA, et al. Improving compliance with safe sleep practices among Black/African American infants discharged from a level III NICU: a quality improvement initiative. BMJ Open Quality. 2025;14(4):e003592. doi:10.1136/bmjoq-2025-003592 ↩
  2. Beverstock A, Carlton S, Lee H, et al. Improving Compliance With Safe Sleep Guidelines for Vulnerable Patients in a Community Safety Net Hospital Neonatal Intensive Care Unit. Pediatric Quality & Safety. 2026;11(2):e877. doi:10.1097/pq9.0000000000000877 ↩
  3. Moon RY, Carlin RF, Hand I, et al. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990 ↩
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  6. Hwang SS, O'Sullivan A, Fitzgerald E, et al. Implementation of safe sleep practices in the neonatal intensive care unit. Journal of Perinatology. 2015;35(10):862-866. doi:10.1038/jp.2015.79 ↩
  7. Napolitano SK, Boswell NL, Froese P, et al. Early and consistent safe sleep practices in the neonatal intensive care unit: a sustained regional quality improvement initiative. Journal of Perinatology. 2024;44(6):908-915. doi:10.1038/s41372-023-01855-6 ↩
  8. Molina AL, Harrison M, Dye C, et al. Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children’s Hospital. Pediatric Quality & Safety. 2022;7(1):e508. doi:10.1097/pq9.0000000000000508 ↩
  9. Vernacchio L, Corwin MJ, Lesko SM, et al. Sleep Position of Low Birth Weight Infants. Pediatrics. 2003;111(3):633-640. doi:10.1542/peds.111.3.633 ↩
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  11. Parks SE, Erck Lambert AB, Shapiro-Mendoza CK. Racial and Ethnic Trends in Sudden Unexpected Infant Deaths: United States, 1995–2013. Pediatrics. 2017;139(6):e20163844. doi:10.1542/peds.2016-3844 ↩
  12. Mathews A, Joyner BL, Oden RP, et al. Messaging Affects the Behavior of African American Parents with Regards to Soft Bedding in the Infant Sleep Environment: A Randomized Controlled Trial. The Journal of Pediatrics. 2016;175:79-85.e2. doi:10.1016/j.jpeds.2016.05.004 ↩
  13. Hirai AH, Kortsmit K, Kaplan L, et al. Prevalence and Factors Associated With Safe Infant Sleep Practices. Pediatrics. 2019;144(5):e20191286. doi:10.1542/peds.2019-1286 ↩
  14. Brown-Madan Y, Williams A, Langston S. Addressing implicit bias and health disparities in a level IV NICU. Journal of Perinatology. 2023;43(12):1494-1496. doi:10.1038/s41372-023-01736-y ↩
  15. Greenwood BN, Hardeman RR, Huang L, et al. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences. 2020;117(35):21194-21200. doi:10.1073/pnas.1913405117 ↩