Physician Directive for Alternative Infant Sleep Position DHS Form

Physician Directive for Alternative Infant Sleep Position

The American Academy of Pediatrics (AAP)* National Institute of Child Health and Human Development (NICHD) and the Minnesota Sudden Infant Death (SID) Center at Children's Hospitals and Clinics of Minnesota recommend back sleeping for babies to reduce the risk of sudden unexpected infant deaths (SUID) due to sudden infant death syndrome, suffocation, and other sleep related causes. The 2011 AAP recommendation further states that an alternative sleep position be considered only for the rare exception of infants for whom the risk of death when sleeping on the back is greater than the risk of SUID when sleeping on the stomach.

Babies sleep safest on their backs.

Minnesota law requires that licensed providers place infants to sleep in a crib, directly on a firm mattress. The provider must place the infant on his/her back for sleep unless the provider has a signed directive from a physician for an alternate sleep position for the infant. Car seats, swings, couches, the floor on a blanket, etc. are not acceptable as an alternative sleep position.

This form is the approved format to direct an alternative sleep position and must remain on file at the licensed location.

In addition, Minnesota law requires licensed providers to use a fitted crib sheet that fits tightly on the mattress and overlaps the underside of the mattress so it cannot be dislodged by pulling on the corner of the sheet with reasonable effort. Nothing may be placed in crib with the infant except the infant's pacifier. These requirements apply to license holders serving infants up to one year of age. Licensed providers may only use cribs that meet requirements specified in statute and must inspect cribs monthly to assure they are safe.

I understand that back sleeping is recommended and is safest for babies. I am directing an alternative position for this infant for the reason(s) stated below. By signing this form I am acknowledging that I am directing only an alternative sleep position and that the infant must always be placed in an approved crib to sleep.

NAME OF CHILD*

CHILD'S DATE OF BIRTH*

Date

*

Place this infant on his/her STOMACH for periods (not recommended); ORPlace this infant on his/her SIDE for sleep periods (not recommended)

Medical Reason(s) for alternate sleep position: (Provide information if necessary)*

Expected duration of need for alternate sleep position*

List the date the infant will be re evaluated for the need for an alternative sleep position by a physician*

Date

Printed Name of PHYSICIAN*

SIGNATURE OF PHYSICIAN*

Clear

DATE*

Date

(Licensed providers must place an infant in a crib to sleep. Car seats, swings, couches, the floor on a blanket, etc. are not acceptable as an alternative sleep position.

* 'Moon RY, American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. Technical Report - SIDS and other sleep related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011. 128(5) available at www.pediatrics.org/cgi/content/full/128/5/