Newborn Safety

Key Messages

Download and Print the Key Messages
These are the main health messages that should be conveyed to all future and new parents. They have been written in the second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic. These messages are intended to address safety issues during the first six weeks of a baby’s life.

key message

Keep your baby safe. Take steps to protect and create a safe environment for your new baby.

Injury is the leading cause of death among children in Canada. Some of the biggest dangers to babies are car crashes, choking, suffocation, strangulation, falling, drowning, and burns. The majority of these injuries can be prevented.

Recognize everyday risks and take precautions. Think about babies and the new skills they develop over time and prepare for new dangers as your baby becomes more mobile. Actively supervise your baby at all times and pay extra attention when there are distractions. The best way to protect your baby form injuries is to:

  • Stay close to your baby.
  • Keep a close eye on your baby.
  • Be able to hear the noises your baby makes.

At all times, when you have to move away from your baby, put your baby in a safe place like a crib, cradle or bassinet.

key message

Provide a safe sleeping environment to reduce the risk of Sudden Infant Death Syndrome (SIDS) and injury or death from suffocation or strangulation.

There are ways to reduce the risks of SIDS and other sleep-related causes of infant death:

  • Breastfeed your baby to reduce the risk of SIDS.
  • Keep your baby in your room next to your bed for the first six months; this is called room-sharing.
  • Right from birth, always place your baby on his back to sleep, at naptime and nighttime.
  • Place your baby to sleep on a separate sleep surface in an age-appropriate crib, cradle, or bassinet that meets current Canadian safety regulations. Keep in mind that:
    • Bed sharing or sharing any sleep surface with your baby is not safe.
    • Items that are not approved sleep surfaces for babies include, baby seats, swings, car seats, bouncers, strollers, slings, playpens, and infant sleeping devices placed into or attached to the side of an adult bed.
    • The safest place for your baby to sleep is in a crib, cradle, or bassinet.
  • Provide a sleep surface that is firm and flat.
  • Ensure your baby’s crib is free of items such as pillows, comforters, duvets/quilts, stuffed animals, bumper pads, positioning supports or other loose or soft bedding materials that could suffocate or smother a baby.
  • If you breastfeed your baby where you sleep, put your baby back to sleep in a crib, cradle, or bassinet when you are ready to go to sleep. Bed sharing or sharing any sleep surface with your baby is not safe. The safest place for your baby to sleep is in a crib, cradle, or bassinet.
  • Dress your baby in comfortable, fitted, one-piece sleepwear.
  • Avoid overheating your baby. A room temperature that is comfortable for you is comfortable for your baby.
  • Provide a smoke-free environment for your baby.

key message

There are many ways to calm and settle your baby.

There are many ways to soothe a baby. If your baby is fussing:

  • Check to see if your baby needs a diaper change.
  • Feed your baby if she is hungry.
  • Add or remove a layer of clothing if she feels cold or warm.
  • Hold your baby skin-to-skin.
  • Use motion, such as going for a walk with your baby in a stroller or carrier.

Some people like to swaddle a fussing baby. Swaddling is controversial. If you choose to swaddle your baby, it is safer if you:

  • Follow your baby’s cues and don’t swaddle if your baby resists.
  • Use a lightweight blanket and dress your baby in a light sleeper or onesie to avoid overheating.
  • Swaddle your baby so that he can bend his legs.
  • Keep your baby’s head uncovered and the hands free so you can see your baby’s feeding cues.
  • Stop swaddling by 2 months of age or before your baby learns to roll over.

key message

Never shake or hit your baby. If you feel unable to cope or are afraid that you may hurt your baby, place your baby in a safe spot. Then call someone for help.

Shaking your baby can cause serious injury to your baby’s neck and can cause brain damage, seizures, and even death. Crying is the main reason caregivers harm a baby.

If you are having a hard time coping with your baby’s crying:

  • Ask for help and have someone who you can call for breaks and rest.
  • Only leave your baby with caregivers you trust and who can control their emotions.
  • If you become angry, put your baby in a safe place (approved crib, cradle or bassinet) and call a close friend or family member.
  • Talk to your health care provider or a family member especially if you are experiencing any of the following:
    • Feeling anxious.
    • Worried more than usual.
    • Less interested in your usual activities.
    • Have been feeling down, sad, irritable, or hopeless for more than two weeks.
  • See the Mental Health key messages for more information about the baby blues and postpartum depression, and to learn about resources in your community.

key message

Use a rear-facing car seat to travel with your baby in any car.

It is safest to use a rear-facing car seat as long as possible. Read the manufacturer’s instructions and follow all age, height, and weight specifications.

Keep in mind the following guidelines:

  • Only use a car seat with the National Safety Mark label on it. Check the packaging or the back of the car seat for this symbol.
  • Check the car seat’s expiry date. Car seats manufactured before December 2012 may not meet safety regulations.
  • Follow the directions that come with the car seat for installation and use.
  • Install the car seat in the back seat at all times.
  • Thread harness straps just at or below your baby’s shoulders. The chest clip should be at armpit level, and the harness should fit snugly.
  • Look for a car seat clinic where your car seat installation can be double-checked by experts.
  • Dress your baby in regular indoor clothing. You can use a blanket on top and a hat for warmth if needed. Snowsuits or bunting bags will interfere with buckling up your baby securely.
  • Only use a car seat that is undamaged. Any signs of damage can make a car seat unsafe. It is not safe to use a car seat that has been in a car crash, even a minor one.
  • Ensure your baby is never left unattended in a car, even for a short time.
  • Be aware of the risk of your baby overheating in a car that is too hot.
  • Place car seats on the floor (safest place) and not on the counter, table, or other high places. Car seats are unsteady and can easily fall from high places.
  • Use a combination stroller/car seat for public transportation. It is the safest option.
  • Use a car seat only for travel. Remove your baby from the car seat once you have reached your destination.

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Protect your baby from falls.

Falls are a leading cause of injury in children under 1 year of age.

Ways to prevent falls include the following:

  • Be within arms’ reach of your baby when your baby is on a raised surface like a change table, counter, or sofa.
  • Deal with distractions when you are finished caring for your baby (example: phone or doorbell ringing), or take your baby with you.
  • Store everything you need to change your baby within easy reach so that you do not have to turn away.
  • Make sure your baby carrier is appropriate for your baby’s age and size so your baby can’t slip out and fall. If you bend over, hold your baby against you with one hand.
  • Assess your home for tripping hazards.
  • Supervise young siblings when they are holding or caring for the baby.

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Protect your baby at bath time from drowning.

A baby can drown in as little as 2.5cm (1 inch) of water.

To reduce the risk of drowning at bath time:

  • Always have at least one hand on your baby when in the bathtub or any water. Bath rings and bath seats are not safe.
  • Have everything you need for bathing at hand so that you never have to turn away.
  • Always supervise your baby when bathing your baby with another child.
  • Ignore distractions such as ringing phones and doorbells during bath time. If you must answer the phone or door, take your baby with you.

key message

Protect your baby from choking, suffocation, and strangulation.

Choking, suffocation, or strangulation may slow or stop a baby’s breathing, and the baby’s brain may not get enough oxygen. This can lead to injury or death.

To reduce the risk of choking, suffocation, and strangulation:

  • Ensure your baby has a safe sleep place to sleep, with no loose items. See the safe sleep tips above.
  • If you choose to give your baby a pacifier (soother), make sure it is one piece with a shield to prevent her from sucking the nipple too far into her mouth. Discard a pacifier that shows signs of wear or is more than two months old. Use a clip to secure it to your baby’s clothing. Ribbons, cord, and necklaces (including amber) can get wrapped around your baby’s neck and are a strangulation hazard.
  • Use a neck warmer instead of a scarf and mitten clips instead of strings.
  • Ensure that your baby is “visible and kissable” when your baby is in a sling or other baby carrier (the face is in view and close enough to kiss; the nose and mouth are uncovered; the neck is straight with the chin off the chest).

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Protect your baby from burns or scalds.

You can take steps to reduce the risk of burns and scalding:

  • Install smoke alarms on every level of the home and in every sleeping area. Test your smoke alarms monthly and change the batteries twice a year.
  • Keep your home smoke-free. Many house fires are caused by careless smoking or children playing with lighters and matches.
  • Set your hot water heater temperature to 49°C (120°F), or put an anti-scald device on your faucets. A baby’s skin burns more easily than an adult’s skin.
  • Before bathing, check the water temperature with your elbow or wrist. It should feel warm, not hot. Bathe your baby away from the faucets, and remove your baby from the tub before running the hot water.
  • Put any hot beverages down before picking up or holding a baby.
  • Do not use a tablecloth that your baby might pull and cause hot liquid to spill.
  • Warm up breastmilk and other baby food in a bowl of hot water and test the milk on your wrist before feeding. Microwaving can create hot spots that can burn a baby’s mouth.

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Protect your baby from the sun.

Too much exposure to the sun has been linked to a higher risk of skin cancer later in life. During hot weather, babies can become dehydrated.

To protect your baby:

  • Limit time in the sun especially between 10 a.m. and 2 p.m.
  • Cover your baby in loose clothing and make sure your baby is wearing a hat with a wide brim.
  • Use a stroller sunshade.
  • Seek shaded play areas or use a sun umbrella. Wait until your baby is 6 months of age before using sunscreen on your baby.
  • Breastfeed more often on hot days to ensure your baby has enough fluids.

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Protect your baby from harmful chemicals.

Babies can be exposed to harmful chemicals such as fumes or dust from cleaning and renovation products and chemicals in plastics. Babies are at greater risk than adults because their immune system is not fully developed. Babies explore the world with their hands and mouths increasing their exposure.

There are ways that you can reduce risks from harmful chemicals:

  • Vacuum or wet-mop once a week.
  • Take your shoes off at the door.
  • Minimize clutter and store toys in a closed container.
  • Wash your hands often using regular soap and warm water. Antibacterial soaps are not recommended.
  • Use non-toxic cleaning products.
  • Keep your baby away from areas that are being renovated. Renovation dust often contains harmful substances such as lead, which is toxic to the developing brain.
  • Choose less toxic paints, finishes, and glues. Look for products labeled VOC-free, zero-VOC, or low-VOC. Open the windows and use fans to bring in fresh air during and after use of these products.
  • Avoid exposure to harmful plastics by avoiding bath toys, shower curtains, and other items that contain PVC or vinyl (a type of soft plastic). These items can contain harmful chemicals called phthalates, which were banned in children’s toys in June 2011.
  • Protect your child from second-hand and third-hand smoke. See the Smoking file for more information.

key message

Protect your baby from insect bites.

Mosquitoes and ticks can carry disease. In some parts of Ontario, there is a risk of West Nile virus from infected mosquitoes and Lyme disease from infected ticks.

To help avoid insect bites you can:

  • Dress your baby in socks and shoes or a sleeper covering the legs and feet. Choose light-coloured and long-sleeved clothing.
  • Avoid being outside at dawn and dusk when mosquitoes are most active.
  • Avoid places where mosquitoes breed and live (standing water).
  • Clean up any standing water in your yard.
  • Keep screens in good repair.
  • Use a fine mesh net to cover your baby’s stroller or playpen when outside. Wait until your baby is 6 months of age before using insect repellent on your baby.

Find out if you live or will visit an area with infected deer ticks. Learn how to protect your family.

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Protect your baby from pets.

Pets can carry disease or cause injury to your baby.
To avoid risks to your baby from pets:

  • Make sure your pet is healthy by having regular veterinary care for vaccinations and when your pet is ill.
  • Supervise your pet or other animals when near your baby.
  • Prevent your pet from licking your baby.
  • Wash your hands after handling pet litter or droppings.
  • Wash your baby’s hands after direct contact with a pet.

key message

Learn more about newborn safety and keeping your baby safe from injury.

You can find out more about newborn safety from the following resources. More suggestions can be found in the Resources and Links section.

Back to the Top

Supporting Evidence

The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Newborn Safety

National and provincial statistics

In Canada, unintentional injuries are the leading cause of death in children and youth, and the majority are preventable. Major causes include motor vehicle collisions, drowning, choking, burns, poisoning, and falls. Families who have a lower income or live in poor housing conditions are often more at risk for injury. In 2008, the leading cause of death from injury in children under 1 year of age was suffocation (n=20, 5.4/100,000) followed by drowning (n=7, 1.9/100,000). Many infants were hospitalized for unintentional injuries (1,343), and the leading causes were falls, poisonings, burns, being struck by or against an object, and motor vehicle accidents.1 In infants and toddlers, the leading causes of injury are choking, suffocation, and strangulation (i.e., 40 percent of injuries in infants under the age of 1 in Canada).2

Safe Sleep

Sudden Infant Death Syndrome (SIDS)

Definition

Sudden Infant Death Syndrome is defined as “the sudden death of an infant less than 1 year of age which remains unexplained after a thorough case investigation, including the performance of a complete autopsy, an examination of the death scene, and a review of the clinical history.”3 The actual cause or causes of SIDS is unknown. Current views, based on available scientific evidence, explain SIDS as a multifactorial disorder arising from a combination of genetic, metabolic, and environmental factors. Terms such as sudden unexplained infant death (SUID) and sudden unexpected death in infancy (SUDI) have emerged in an attempt to group all infant deaths possibly related to the infant sleeping environment. While definitions of these terms have not been consistent enough to make them universally acceptable, risk factors that may contribute to unintentional death from suffocation due to overlaying or entrapment are examined and considered in guidelines for infant safe sleep practices.3,4

Statistics and trends

In 2004, SIDS accounted for 5 percent of all infant deaths (i.e., birth to 1 year of age) and 17.2 percent of postneonatal deaths (28 days to 1 year of age). SIDS can occur at any time during the first year of life but peaks between two and four months with fewer SIDS deaths occurring after six months.3 Younger maternal age, higher parity, multiple birth, preterm birth, and low birth weight are associated with higher risk of SIDS. There has been a steady and dramatic decline in the rates of SIDS since the late 1990s from 78.4 deaths per 100,000 live births in 1991 – 1995 to 34.6 in 2001 – 2005. This decline has been attributed to changes in infant care and health risk practices such as an increase in the use of supine position for sleeping, increased breastfeeding rates, and decreased maternal smoking.5

Infant mortality rates due to Sudden Infant Death Syndrome have fallen in Canada in recent decades. SIDS rates vary widely among Canadian provinces and territories. Recent data indicate that Quebec has the lowest rate while Nunavut has the highest. The decrease in SIDS may be explained by a decrease in risk factors such as maternal smoking during pregnancy, and an increase in protective behaviours such as placing babies on their back to sleep and breastfeeding.6

Asphyxia

Asphyxia is identified as the cause of death when an infant is found with the airway obstructed by an object or a person’s body, or there is inadequate access to air such as in situations of entrapment, overlying, or strangulation by something around the infant’s neck. Deaths from asphyxia are not included in the unexplained death or SIDS categories as the cause has been determined. However, unsafe factors in the sleep environment are often associated with these deaths.4

Safe sleep guidelines

While the biological causes and mechanisms that predispose some infants to SIDS relative to non-affected infants is unknown, evidence has led to the adoption of practices that are known to reduce the risk of SIDS and unexpected infant death due to suffocation or strangulation related to the sleep environment.

Safe sleep practices include:3,7

  • Placing babies on their back to sleep.
  • Placing babies on a separate sleep surface in an approved crib, cradle, or bassinet and avoiding bed sharing with an adult who is asleep.
  • Keeping babies at their parent’s bedside for the first six months (i.e., room sharing).
  • Ensuring a safe sleep environment that is free of pillows, duvets/quilts, bumper pads, toys or positioning aids.
  • Breastfeeding.
  • Providing a smoke-free environment.

Once infants are able to roll from their back to their stomach or side, it is not necessary to reposition them onto their back. Other devices such as strollers, car seats, or swings are not intended for infant sleep and are considered to put the infant at risk of airway obstruction when the head falls forward.3,4

While there is widespread acceptance of the evidence for infant safe sleep practices (e.g., supine position, breastfeeding, smoke-free environment), there continues to be some discussion around several topics such as bed sharing and swaddling.

The potential role of pacifiers in reducing the risk of SIDS is controversial. While some evidence has shown an association between the use of a pacifier and a reduced risk of SIDS, the pathophysiology of SIDS, upon which pacifiers may exert a positive effect, remains unclear. Paediatric experts conclude that “no recommendation to use pacifiers to reduce the risk of SIDS can be made at this time. However, the evidence is sufficient that paediatricians and other health care professionals should be cautious before routinely advising against their use.”8 Breastfeeding advocates and experts have disputed this conclusion and do not recommend the use of pacifiers before lactation is well established (around 6 weeks of age).9,10

Bed sharing

Systematic literature reviews have consistently concluded that infants who sleep in the same bed as a sleeping adult are at increased risk of SIDS or unexpected infant death from other causes such as suffocation or strangulation. The risks of bed sharing are especially high in the first four months of life if the caregiver smokes, is under the influence of alcohol or sedating drugs, overly tired, or if the sleep surface is a sofa or chair.3,4,11 Studies have shown a three- to five-fold increase in the risk of death for infants who share a bed with an adult even if none of the other risk factors are present (e.g., smoking, alcohol). Risks are highest under 3 months of age.4,12,13 The recommendation for infants to sleep on a separate sleep surface (i.e., an approved crib, cradle, or bassinet) and not in bed with an adult is universal in contemporary infant safe sleeping guidelines.3,7,14.

In Ontario, the Registered Nurses’ Association of Ontario (RNAO) in their Clinical Best Practice Guideline on Safe Sleep, encourages health care providers to educate parents about the risks involved with sharing a sleep surface with their baby. They also recommend that parents should be encouraged to find alternative ways of soothing their baby and to always place their baby on their own sleep surface. 4 The Perinatal Services of British Columbia Safe Sleep Environment Guideline (executive summary and Appendix A) outlines their recommendations made based on their review of the current evidence.

Objections to the advice against bed sharing exist and are usually based on a defense of this practice as a cultural or family norm and beliefs that bed sharing facilitates breastfeeding.12,15 It should be noted that safe sleep guidelines do not prohibit babies being brought to bed for breastfeeding and do acknowledge cultural differences in this practice. Based on the evidence, parents are encouraged to breastfeed frequently and as often as the baby is interested – including through the night which can be easily done by breastfeeding in bed. However, the advice to reduce the risk of SIDS is to place the baby back into the crib, cradle or bassinet at the mother’s bedside after breastfeeding.11,14

Swaddling

Swaddling is an age-old practice used by parents around the world to calm their crying babies and settle them to sleep. Swaddling has also been used to keep babies warm at vulnerable times (e.g., following birth) and in colder climates with poorly-heated environments.16 Current evidence supports the superiority of skin-to-skin care wherever possible to keep babies warm- especially after birth and in the early days of life.

Swaddling after the early prenatal period is, today, a controversial issue, and although national bodies such as the Canadian Paediatric Society17 and the College of Family Physicians of Canada18 do not discourage swaddling, there are no specific guidelines for professionals or parents regarding this practice. The Registered Nurses’ Association of Ontario states that in light of the fact that there is currently no evidence regarding safe swaddling of infants, parents should be cautioned about swaddling their baby.4

Swaddling has been shown to be an effective response to infant crying and to promote sleep. Swaddling benefits neurodevelopment and self-regulation in preterm infants and is associated with decreased parent anxiety and increased satisfaction.16 Swaddling is thought to be an effective strategy to promote sleep in babies who are kept awake from startles (i.e., Moro reflex) which occur most often when the baby is placed in the recommended supine position. Swaddling is a preferable option for exhausted parents who may otherwise resort to placing the baby prone (babies sleep more deeply in the prone position), sitting up with the baby on a couch or chair, or who are distressed by persistent infant crying.,20

A descriptive study of 103 parents found that 80 percent of parents who swaddled their infants found it effective for comfort and those who swaddled were more likely to put their babies in a supine position for sleeping. Authors conclude that “swaddling may be a strategy for parents of infants who have difficulty sleeping in a supine position.”20

However, caution is warranted as a swaddled baby who is prone has an increased risk of SIDS possibly related to decreased arousal associated with swaddling and SIDS16. Also, traditional tight swaddling which used to be common in Canadian hospitals or binding used in some cultures (in which legs are maintained in extension) increases the risk of hip dysplasia.16,21 Current practice advice for safer swaddling includes using a light blanket with the head uncovered, allowing freedom of movement of legs and hips and, to discontinue the practice by 2 months of age before the baby learns to roll over.14,16,18

There are swaddling devices on the market such as wearable blankets with hook and loop fasteners or other types of fasteners. There are few studies on the relative safety of these devices. However, a retrospective review of infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling reported to the Consumer Product Safety Commission between 2004 and 2012 found that 58 percent of deaths were attributed to positional asphyxia related to prone sleeping and 92 percent involved additional risk factors most commonly soft bedding. The report concludes that reports of sudden unexpected death in swaddled infants are rare. Risks can be reduced by placing an infant supine and discontinuing swaddling as soon as the infant attempts to roll over. Risks can be further reduced by removing soft bedding and bumper pads from the sleep environment. When using commercial swaddle wraps, fasteners must be securely attached.22

Baby wearing

Caution is advised with the use of infant carriers and slings used for baby wearing due to possible impingement of the infant’s airway while the infant is carried in a prone position on the adult chest. Guidelines for safe positioning of infants in kangaroo skin-to-skin care also apply to baby wearing.

These safe-positioning guidelines include ensuring the:

  • Infant’s head is turned to one side.
  • Infant’s face can be seen.
  • Infant’s nose and mouth are visible and uncovered.
  • Infant’s neck is straight not bent.23

Health Canada advises that safe baby wearing means the baby is “visible and kissable”24 meaning:

  • Baby’s face is in view at all times.
  • Baby is high and upright.
  • Baby’s chin is up.
  • Baby’s back is supported, and baby is snug against the wearer.
  • Baby is close enough to kiss.

Parents are advised to clothe their baby for sleep in a one-piece sleeper. Sleep sacks (a one-piece sleeper without separate legs) are commonly used to keep a baby comfortable while sleeping. Caution about using the correct size of infant sleep sack or wearable blankets is advised as there is a risk if the sleep sack is too large that the baby may slip inside, and the baby’s face may become covered.4

Positional plagiocephaly

To counteract any effects of regular back sleeping on muscle development or the chance of developing positional plagiocephaly, commonly referred to as flat head, parents are advised to ensure that when awake the baby is positioned so pressure is off the back of the head. Encourage parents to carry their infant and limiting the time that the baby is in a car seat, baby seat, baby swing, or lying supine while awake is advised. Supervised tummy time several times a day, while the baby is awake, is recommended. This benign condition can occur as early as two to three months. Once babies can lift their head well when prone and become mobile, the risk of plagiocephaly is reduced.3,4

Abusive Head Trauma (AHT)

Shaken Baby Syndrome (SBS)

Shaken Baby Syndrome is a term used by professionals and the public to describe head trauma inflicted on infants and young children. The term Abusive Head Trauma is being used more often to reflect advances in the understanding of the underlying pathologic mechanisms. It is caused by violent shaking, throwing, hitting, or slamming and is a form of child abuse that can lead to serious brain injury or death. Abusive Head Trauma can occur when a parent or another caregiver becomes frustrated and angry often because the baby won’t stop crying.25,26,27

The Canadian Paediatric Society (CPS) defines Abusive Head Trauma as a specific form of traumatic brain injury that is medically defined by the constellation of symptoms, physical signs, laboratory, imaging and pathologic findings that are a consequence of violent shaking, impact, or a combination of the two.25 There may be no external signs of injury and presenting features, which may or may not be present in every case, include an altered level of consciousness, lethargy, poor feeding, irritability, vomiting, respiratory distress or apnea, or seizures. Examination and investigation may show intracranial and/or retinal hemorrhage, brain injury, and fractures of the skull or other bones.28 AHT is reportable by law25,28

The prevention of Shaken Baby Syndrome has been a priority preventive health message for parents of newborns and infants with a focus on how to cope when a baby won’t stop crying and how to safely manage caregiver frustration. Careful choice of child care providers is also advised.27,29

If a caregiver feels like they are getting angry and might lose control, they are advised to try the following:27

  • Take a deep breath and count to 10.
  • Place the baby in a safe place, leave the room, and let the baby cry alone for about 10 to 15 minutes.
  • Call someone for emotional support.
  • Call the child’s doctor. There may be a medical reason why the baby is crying.
  • Be patient. Colicky and fussy babies eventually grow out of their crying phase. Keeping the baby safe is the most important thing to do. Even if you feel frustrated, stay in control and handle your baby with care.

Transportation

Car seat safety

Motor vehicle collisions remain the leading cause of death in Canadian children. Car seats, when used correctly, reduce the risk of injury by about 70 percent. Many car seats are not used correctly, and the most prevalent errors are:30

  • Selecting the wrong stage of car seat for the weight and/or height of the child.
  • Seat not tightly secured.
  • Harness not tight enough.
  • Chest clip not at armpit level.

Most health care providers lack knowledge about how to choose and safely use an appropriate car seat for infants and children. The Canadian Paediatric Society has prepared a detailed position paper that outlines these points in detail and includes diagrams to explain the stages of car seats and safe transportation of infants and children in motor vehicles.30

Transport Canada31 specifies four stages for keeping children safe in a vehicle with detailed specifications for each.

  • Stage 1: Rear-facing seats.
  • Stage 2: Forward-facing seats.
  • Stage 3: Booster seats.
  • Stage 4: Seatbelts.

Rear-facing car seats (i.e., stage 1) should be used for infants who weigh up to 10 kg (22 lb), are up to at least 1 year of age, and able to walk. This can be achieved by using an infant-only rear-facing seat or a convertible (infant/child) seat that can be used rear-facing for infants and forward-facing for older children. When the weight or height limits have been exceeded for an infant-only seat, parents should choose an infant/child seat that can be used for greater weights and/or heights in the rear-facing position. Infants who weigh less than 10 kg at 1 year of age should continue to ride in the rear-facing position. Rear-facing infant/child restraints may continue to be used beyond 10 kg and 1 year of age, in accordance with the manufacturer’s instructions for height and weight limitations; parents should be encouraged to continue to use a rear-facing seat as long as the height and weight limitations allow. All rear-facing car seats must be secured to the vehicle with the vehicle seatbelt or the universal anchorage system (UAS), also referred to as the LATCH system in American literature.

Public transportation

Most forms of public transportation (with the exception of taxis and airplanes) don’t have seatbelts, so there is no method for securing a car seat. A combination stroller/car seat is the safest option for public transportation as once the stroller is folded up, the infant can be kept in the seat on the bus or train and be provided some protection in a crash. With taxi or air transportation, the seat can be secured with a seatbelt.32

Other Injuries

Falls

Falls are the leading cause of hospital admissions from injury for those aged birth to 9 years and constitute more than all other injuries combined. Most often children fall from furniture or stairs.1 Newborns are vulnerable to falls right from birth and this risk accelerates as the baby learns to roll over and becomes more mobile. Infants should never be left unsupervised on an elevated surface. When a caregiver has to move away from a baby, they should put the baby in a safe place like a crib. Falls, like other injuries, are most likely to happen at busy times of the day. Avoiding tripping hazards in and outside of the home will reduce the risk of the baby falling while being carried. Special attention is also needed when taking a baby in and out of an infant carrier or sling and when leaning over once the baby is in the sling. It is important to supervise siblings when they are holding the baby. Gates at the top and bottom of stairs are important once the infant becomes mobile.1,33

Water safety

Drowning is a leading cause of death and injury in children. Babies under 1year of age are more likely to drown in the bathtub than in any other place and can drown in as little as 2.5 centimetres (1 inch) of water in just a few seconds.1

There are several important ways to prevent drowning at bath time:

  • Infants should always be supervised by an adult while in the bath. The baby should always be within both sight and reach of the adult.
  • Bath seats and bath rings should not be used. These bath aids are dangerous as they can give caregivers a false sense of security (e.g., parents report that they are more comfortable leaving their baby alone in the bathtub for a few moments if the baby is in a bath seat). However, the infant can slip under the bath ring and the ring can trap the baby under the water.
  • Infants should never be left alone in a bathtub with a sibling.1,33

Choking, suffocation, and strangulation

Choking, suffocation, and strangulation are the leading causes of unintentional injury and death in infants and toddlers. The following information from the CPS Injury Prevention Committee highlights key points.2 Morbidity associated with choking, suffocation, and strangulation injuries can be significant and include anoxic brain injury and esophageal perforation. Nearly all choking, suffocation, and strangulation injuries and deaths are preventable. Encourage parents and other caregivers to learn CPR and choking first aid and offer information about preventing these injuries.

Deaths due to choking, suffocation, strangulation, or entrapment are the result of asphyxia, a lack of oxygen supply to the brain. Asphyxia may also occur in enclosed spaces such as a toy box, unused refrigerator or freezer, a grain silo, or the trunk of a car.

Children under 3 years of age are at highest risk of mechanical airway obstruction because their airway is incompletely developed, chewing and swallowing are still being developed, and they put many things in their mouth (infants put virtually any item they come in contact with in their mouth). Food and latex balloons are the leading objects involved in choking cases. Most foods implicated are small, round or cylindrical in shape, and conform to the contours of a child’s airway (e.g., hot dog rounds, whole grapes, carrot slices, peanuts, seeds, and hard candy). Talk to parents of newborns about how to prevent choking as their infant becomes mobile, develops hand-to-mouth skills, and is introduced to solid foods.

Infants are most vulnerable to suffocation and strangulation through unsafe sleep environments (see above). Strangulation can also be caused by anything that gets around a baby’s neck such as a blind cord, drawstring on clothing, or necklace. Infants should never have anything tied around their necks. Amber teething necklaces represent strangulation and choking hazards, are not effective, and should not be used.34

Burns or scalds

Babies and children are at high risk for burns because their skin is thinner than an adult’s skin. A child’s skin burns four times more quickly and deeply than an adult’s at the same temperature. Serious burns can have long-term consequences for a child. They often must have many skin grafts and may have to wear compression garments for up to two years. Because children are always growing, they are likely to have scarring and contracting of the skin and underlying tissue as they heal. Many children have resultant disfigurement, permanent physical disability, and emotional difficulties.1

Infants can be protected from burns or scalds in a variety of ways including:18,33

  • Installing smoke alarms on every level of the home and in every sleeping area. Smoke alarms should be tested monthly and batteries changed twice a year (e.g., when changing the clocks in the spring and fall for daylight saving time).
  • Banning smoking in the home. Many house fires are caused by careless smoking or children playing with lighters and matches.
  • Setting the hot water heater temperature to 49°C (120°F) or putting an anti-scald device on faucets.
  • Using warm, not hot, water to bathe an infant and checking the temperature with an elbow or wrist before bathing. Bathe the baby away from the faucets.
  • Never carrying a baby and a hot drink at the same time.
  • Never heating breastmilk or other baby food in a microwave as dangerous hot spots can burn a baby’s mouth.

Sun protection

Sunburns and too much time spent in the sun without skin protection have been linked to a higher risk of skin cancer later in life.33 In a hot climate, infants can become dehydrated. Skin can also be burned by touching hot surfaces such as pavement, metal slides, or car doors. Infants should never be in the direct sunlight especially at peak hours between 10 a.m. to 2 p.m. When outdoors, babies should be covered with loose clothing and should wear a hat with a wide brim. It is safest to place the baby in shady areas and to use a stroller with a sunshade. Sunscreen should not be used before 6 months of age. Infants can be kept hydrated by more frequent breastfeeding. Parents should watch for signs of overheating such as excess sleepiness, lethargy, or poor feeding and seek medical attention in such cases.

Insects

Mosquitoes, ticks, and biting flies can carry disease. In some parts of Canada, there is a risk of West Nile virus caused by infected mosquitoes and Lyme disease caused by infected ticks. Flies in Canada do not carry disease and disease from other insects is very rare.33

Insect repellent should not be used for infants under 6 months of age, and older children should only be exposed to small amounts of DEET (N,N-diethyl-meta-toluamide). For children aged 6 months to 2 years up to 10 percent concentration may be used, applied no more than once daily. One application of 10 percent DEET offers three hours of protection against mosquitoes.35

Not all products have the same concentration of DEET and repellents with a higher concentration provide a longer duration of protection. In Canada, products with a concentration of DEET above 30 percent are not available.35

Advice to help reduce infants’ exposure to mosquito and tick bites includes:

  • Covering strollers and playpens with a fine mesh netting.
  • Dressing the baby in light-coloured, long pants and long-sleeved shirts and ensuring the feet are covered.
  • Avoiding being outdoors when mosquitoes are most active (i.e., dawn and dusk).
  • Avoiding places where mosquitoes breed and live (i.e., standing water).
  • Cleaning up any standing water in the yard.
  • Keeping screens in good repair.
  • When in an area where there is a known prevalence of deer ticks, thoroughly inspecting clothing and skin for ticks after being outdoors.

Local health units are a good source of information about the local conditions and risks of exposure to West Nile virus and Lyme disease.

Pets

Pets can be the source of infection or injury for infants. Parents are advised to ensure any pet in the house is healthy by seeking regular veterinary care for vaccinations or treatment when ill and watching for any contact the pet has with other animals that might carry disease. Pets should not be allowed to roam unsupervised in the infant’s room and should have a separate sleep area of their own. Infants can be scratched or bitten by a frightened or irritated pet and should never be left unsupervised with a pet.

Parents should handle pet litter or faeces carefully and always wash their hands afterwards. Reptiles such as turtles or snakes can carry salmonella so infants should not be allowed near them and hand washing by adult handlers is important. Some pets can be dangerously aggressive and should be kept out of the home (e.g., wild animals, ferrets, monkeys). Parents should be alert for any signs of an allergic reaction to the pet and seek medical advice if needed.36

Environmental Health

Infant and young child vulnerability

During the past decade, there has been increasing attention on the role of environmental chemicals/pollutants in child health and development. Infants and young children have higher exposure to environmental toxicants as, per unit of body weight, children breathe, drink, and eat more than adults. Their bodies, including their brains and organ systems, are developing and behaviours such as hand-to-mouth activity, crawling on the floor, and outdoor play increase their exposure. Children are exposed to environmental contaminants in utero and have a longer lifetime than adults to accumulate the effects of toxins. Generally, information is lacking on patterns of children’s exposures to various types of contaminants in both indoor and outdoor environments, air, water, and food.37,38

Lead, a well-established neurotoxin leading to poor brain development in children, has been banned from a number of products (e.g., paints, gasoline). However, lead screening is recommended for infants and children who may still be at risk of environmental exposure to lead (e.g., living in older housing [pre-1978] under renovation and/or with peeling or chipped paint, living near a source of lead contamination, having a family or neighbourhood history of lead poisoning, or being a refugee).18,39

Limiting exposure to key toxins and other exposures

The Canadian Partnership for Children’s Health and Environment (CPCHE) reports37 on the importance of environmental exposures (e.g., lead, mercury, air pollution) on neurodevelopment and behaviour, reproduction, endocrine disruption, and cancer in children and young adults. Topics of concern include the interactions among determinants of child health, as well as the health effects of aggregate and cumulative exposures to pollutants and to widely varied chemical mixtures, the health effects of low-dose exposures as well as the timing of specific ‘windows of vulnerability,’ potential for intergenerational effects, and possible associations between early life exposures and the adult onset of disease.

Parents can reduce exposure to environmental contaminants by:

  • Using non-toxic cleaning products.
  • Minimizing exposure to dust in the home (especially renovation dust).
  • Reducing exposure to toxins such as bisphenol A (BPA) and phthalates in plastics and mercury in fish.
  • Reducing exposure to radon starting with how to test for radon in the home.40

For more information about how women can protect their unborn baby see the Safety during Pregnancy file.

Referrals

When to refer

Health care providers should be alert to identify families at increased risk of childhood injury. Risk factors include low socioeconomic status, low education, young age, lack of social support, poor housing, or especially a history of abuse or neglect. Any suspicion of injury due to abuse or neglect requires mandatory reporting to the local Children’s Aid Society. In Ontario, child protection services are provided by the Ontario Association of Children’s Aid Societies and governed by the Child and Family Services Act.

Where to refer

Any suspicion of injury due to abuse or neglect requires mandatory reporting to the local Children’s Aid Society.28 Families who could benefit from education regarding infant safety can be referred to the provincial Healthy Babies Healthy Children Program via the local health department. Public health nurses and lay visitors offer a home visiting program for health promotion, injury prevention, and referral to local resources such as parenting programs.

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Resources & Links

Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Reports/Publications

Websites

Helplines

  • 9-1-1 (for medical emergency)
  • Motherisk Helpline 1-877-439-2744
  • Telehealth Ontario 1-866-797-0000

Prenatal Education Provider Tools

Client Resources and Handouts

Videos

Apps

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References

References

  1. Parachute (formerly Safe Kids Canada). About Injuries. Retrieved from http://www.parachutecanada.org/injury-topics
  2. The Canadian Paediatric Society Injury Prevention Committee. (2012). Preventing choking and suffocation in children. Paediatr Child Health, 17(2):91-2.
  3. Public Health Agency of Canada (PHAC), Health Canada, Canadian Institute of Child Heath, Canadian Foundation for the Study of Infant Deaths. (2011). Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada. http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance_0-2/sids/index-eng.php
  4. Registered Nurses’ Association of Ontario. (2014). Working with families to promote safe sleep for infants 0-12 months of age. Retrieved from http://rnao.ca/sites/rnao-ca/files/PromoteSafeSleepForInfant.pdf
  5. Gilbert NL, Fell DB, Joseph KS, Liu S, León JA, Sauve R. for the Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. (2012). Temporal trends in sudden infant death syndrome in Canada from 1991 to 2005: Contribution of changes in cause of death assignment practices and in maternal and infant characteristics. Paediatric and Perinatal Epidemiology, 26(2), 124–130, doi/10.1111/ppe.2012.26.issue­2/issuetoc
  6. Public Health Agency of Canada. Sudden infant death syndrome (SIDS) fact sheet. Retrieved from http://www.phac-aspc.gc.ca/rhs-ssg/factshts/mat_sids-smsn_mat-eng.php
  7. Public Health Agency of Canada (PHAC). (2014). Safe Sleep for Your Baby (booklet & video). Retrieved from http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance_0-2/sids/ssb_brochure-eng.php
  8. (2003, reaffirmed 2014) Position statement. Recommendations for the use of pacifiers. Paediatrics and Child Health, 8(8); 515-519.
  9. (2011). Policy Statement. SIDS and other sleep related infant deaths. Pediatrics, 128:1030-1039.
  10. Jaafar, S., Jahanfar, S., Angolkar, M., Ho, J. (2012). Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. EBM Reviews – Cochrane Database of Systematic Reviews, 7, 2012.
  11. Leduc, D., A Côté, A. & Woods, S. for Canadian Paediatric Society, Community Paediatrics Committee. (2004, 2014).Recommendations for safe sleeping environments for infants and children. Paediatr Child Health, 9(9), 659-63. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724135/
  12. Vennemann, M. M., Hense, H. W., Bajanowski, T., Blair, P. S., Complojer, C., Moon, R. Y., et al. (2012). Bed sharing and the risk of sudden infant death syndrome: Can we resolve the debate? The Journal of Pediatrics, 160(1), 44- 48 e42.
  13. Carpenter, R., McGarvey, C., Mitchell, E. A., Tappin, D. M., Vennemann, M. M., Smuk, M., et al. (2013). Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case– control studies. BMJ Open, 3:e002299.
  14. Best Start Resource Centre. (2014). Sleep Well, Sleep Safe. Retrieved from http://www.beststart.org/resources/hlthy_chld_dev/pdf/BSRC_Sleep_Well_resource_FNL_LR.pdf
  15. Bartick, M. & Smith, L. (2014). Speaking out on safe sleep: Evidence-based infant sleep recommendations. Breastfeeding Medicine, 9(0). Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0113
  16. Van Sleuwen, B., Engelberts, A. … (2007). Swaddling: A systematic review. Pediatrics, 120, e1097-e1106. Retrieved from http://pediatrics.aappublications.org/content/120/4/e1097.short
  17. Canadian Pediatric Society. (2014). Colic and crying. Retrieved from http://www.caringforkids.cps.ca/handouts/colic_and_crying
  18. Rourke, L., Leduc, D., & Rourke, J. (2011). Rourke Baby Record. Endorsed by the College of Family Physicians of Canada & Canadian Pediatric Society. Retrieved from http://www.cps.ca/tools/RBRNational.pdf
  19. Karp, H. (2008). Safe swaddling and healthy hips: Don’t throw the baby out with the bathwater. Pediatrics, 121(5), 1075-76.
  20. Oden, R., Powell, C., Sims, A., Weisman, J., Joyner, B., & Moon, R. (2012). Swaddling. Will it get babies on their back to sleep? Clinical Pediatrics, 51(3), 254-259.
  21. Clarke, N. (2014). Swaddling and hip dysplasia: an orthopaedic perspective. Archives of Diseases in Childhood, 99, 5-6.
  22. McDonnell E. & Moon R. (2014). Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling. Pediatrics 164(5):1152-6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24507866
  23. Ludington-Hoe, S. & Morgan, K. (2014). Infant assessment and reduction of sudden unexpected postnatal collapse risk during skin-to-skin contact. Newborn & Infant Nursing Reviews, 14(1), 28-33. http://dx.doi.org/10.1053/j.nainr.2013.12.009
  24. Health Canada. Consumer Product Safety. Poster: Visible & Kissable. Retrieved from http://www.hc-sc.gc.ca/cps-spc/pubs/cons/kissable-visible-calin-eng.php
  25. Canadian Pediatric Society. (2008). Position statement: Multidisciplinary guidelines on the identification, investigation and management of suspected abusive head trauma. Retrieved from http://www.cps.ca/documents/AHT.pdf
  26. Christian, C., Block, R. and the Committee on Child Abuse and Neglect Abusive Head Trauma in Infants and Children. (2009). Abusive head trauma in infants and children. Pediatrics, 123:1409–1411. Retrieved from http://pediatrics.aappublications.org/content/123/5/1409.full.pdf
  27. American Academy of Pediatrics. (2015). Abusive head trauma: How to protect your baby. Retrieved from http://www.healthychildren.org/English/safety-prevention/at-home/pages/Abusive-Head-Trauma-Shaken-Baby-Syndrome.aspx
  28. Novak, C. (May, 2015). CPS statement: Abusive head trauma. PedsCases. Retrieved from http://www.pedscases.com/cps-statement-abusive-head-trauma
  29. Government of Alberta. (2013). Shaken baby syndrome. Retrieved from https://myhealth.alberta.ca/health/pages/conditions.aspx?hwid=hw169815&#hw169817
  30. van Schaik, C. for Canadian Paediatric Society, Injury Prevention Committee. (2008). Transportation of infants and children in motor vehicles. Paediatr Child Health, 13(4):313-8. Retrieved from http://www.cps.ca/documents/position/car-seat-safety
  31. Transport Canada. Keep kids safe. Retrieved from https://www.tc.gc.ca/eng/motorvehiclesafety/safedrivers-childsafety-car-time-stages-1083.htm
  32. Tombrello, S. How can I use a car seat or booster seat on public transportation? Retrieved from http://www.babycenter.com/404_how-can-i-use-a-car-seat-or-booster-seat-on-public-transport_69929.bc
  33. Canadian Pediatrics Society – Caring for Kids. Keep your baby safe. Retrieved from http://www.caringforkids.cps.ca/handouts/keep_your_baby_safe
  34. Health Canada – Consumer Products. (2102). Is Your Child Safe? Retrieved from http://hc-sc.gc.ca/cps-spc/pubs/cons/child-enfant/index-eng.php
  35. Health Canada. (2014). Insect repellents. Retrieved from http://healthycanadians.gc.ca/healthy-living-vie-saine/environment-environnement/pesticides/insect_repellents-insectifuges-eng.php
  36. Canadian Pediatric Society. (2010). Pet safety: Tips for bringing a pet into your home. Retrieved from http://www.caringforkids.cps.ca/handouts/pet_safety
  37. (2008). Report of the national policy consultation on children’s health and environment Retrieved from http://www.healthyenvironmentforkids.ca/resources/report-national-policy-consultation-childrens-health-and-environment
  38. The Canadian Association of Physicians for the Environment (CAPE). The environmental health project. Retrieved from http://www.cape.ca/children/
  39. Abelsohn, A. & Sanborn, M. (2010). Lead and children: Clinical management for family physicians. Canadian Family Physician. 56(6), 531-535.
  40. The Canadian Partnership for Children’s Health and Environment (CPCHE) (2011 & 2012). Creating healthy home environments for kids: Top 5 tips (Video, Brochure, Resources for professionals). Retrieved from healthyenvironmentforkids.ca

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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood