From the day your child is born, her sleep is a top priority on your mind. Newborns and infants need a LOT of sleep for healthy growth, and you want them to nap and sleep well so that you can have a little rest yourself!
Unfortunately for a lot of babies, its hard to adjust to sleeping in the outside world. They just spent 9 months in a dark, cozy, warm space and now have to figure out how to be comfortable in an entirely new environment. Add in the rapid physical and mental growth they are working through, and some (or many) days and nights can be incredibly difficult.
Naturally, you are going to want to do anything you can to help your child sleep comfortably and well. But how do you create a sleep environment for her that is safe?
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A QUICK HISTORY OF SAFE SLEEP PRACTICES IN THE US
In 1969, the term SIDS, or Sudden Infant Death Syndrome, was coined to describe what seemed to be unexpected deaths in otherwise healthy babies after birth. 1 Congress officially designated SIDS as a significant public health issue in 1974, directing the National Institutes of Health to conduct research on it.
By the early 1990s, study results seemed to indicate a link between sleep positions and SIDS. This prompted recommendations to place infants on their backs or sides to sleep instead of their stomachs. This was revised in 1996 to recommend back only sleeping positions.2
In 1994, the “Back to Sleep” public education campaign kicked off. Massive efforts were undertaken to raise awareness and spread the new recommendations.2 Within 5 years of the launch of the campaign, SIDS rates in the US dropped more than 50%.3
This is incredible, but even one preventable death is one too many. Since then, educational efforts and research have expanded to include prevention of all sleep-related infant death, including suffocation and accidental strangulation in bed.3
The term SUID (Sudden Unexpected Infant Death) is now used as an umbrella term by the CDC to refer to any unexpected death of an infant under the age of 1 with no immediately obvious cause. SIDS and accidental suffocation and strangulation in bed would fall under this term if you see it used.4
WHAT ARE THE CURRENT RECOMMENDATIONS TO PRACTICE SAFE SLEEP?
The AAP (American Academy of Pediatrics) most recently revised their recommendations in 2016. Below is a summary of the current guidelines. They are applicable (unless otherwise specified) to children under the age of 1 year.5 If you wish to view the full policy statement that goes into much further detail, please visit the 2016 Recommendations for a Safe Infant Sleeping Environment.
1. BACK TO SLEEP
Always lay your infant down to sleep on his back. Studies have shown that back sleeping does NOT increase the risk of choking, even in babies with reflux and those that need tube feedings.
Tummy time is of course important to your child’s development, but it should only be practiced when your baby is both awake and under constant observation. If you have to walk away for any reason, move your child to his back.
Additionally, avoid using wedges to elevate the end of the bed. This practice has been shown to be ineffective in alleviating reflux symptoms. The angle puts your child at risk for sliding into a position that could interfere with his breathing.
I can tell you from experience that this sliding around CAN AND DOES happen. Before I knew about this safety point, I tried a wedge under the mattress when my son had a cold. I just wanted to try and help his congestion at night. He DID slide on it. Every time I tried it. Luckily he was not hurt, but it goes to show it’s a possibility.
How long do I need to continue laying my child on his back for sleep? Currently, the recommendations are in place for infants up to the age of 1 year. HOWEVER, once your child is able to roll from back to tummy and tummy to back on his own, you can let your child remain and sleep in whatever position he rolls into. Make sure, though, to keep the space free of loose or soft bedding because there is still a risk of suffocation if your child rolls onto that.
2. FIRM SLEEP SURFACE
Place your baby on a firm surface (like a firm mattress) covered only by a fitted sheet. Any additional bedding increases risk of suffocation and SIDS.
If you want to use a mattress protector, make sure it is thin and tight-fitting. Hey, accidents happen and no one wants to have to clean pee, poop, or vomit out of a mattress. I love the protector I bought because it meets these requirements and encloses the entire mattress to help with allergens too!
What is the definition of firm? Basically, when your child is lying on the surface, it keeps its shape and does not conform to your baby’s head while she on it. So, for example, a memory foam mattress would not be considered a firm sleep surface because it indents when you are lying on it.
Currently, cribs, portable cribs, bassinets, and portable play yards are recommended as long as they meet the Consumer Product Safety Commission (CPSC) standards. This would include having slat spacing of less than 2-3/8 inches, no drop-sides, and (if using one) a mattress that fits snugly inside.
You should only use a mattress designed for the product you are using because gaps can be hazardous. If your crib has any missing hardware or was broken at any point, DO NOT USE IT, even if it was “fixed”. It’s just not worth the risk.
Make sure that the sleeping area has no dangling cords, electrical wires, or similar hazards that could pose a strangulation risk. (I had to make sure my childrens’ cribs were far enough from the window that the cords for the blinds could not be reached or accidentally get caught).
Bedside Sleepers and In-Bed Sleepers
CPSC has established safety standards for bedside sleepers, but not for in-bed sleepers. Currently there are NO RECOMMENDATIONS either for or against either of these types of products. There have been no studies on their association with SIDS or other types of injury or death.
Sitting Devices (including car seats, strollers, swings, infant carriers, slings)
These types of products are not recommended for routine sleep, especially for infants under 4 months old. Babies can end up in positions that obstruct their airways and younger infants are limited in their ability to move out of those positions.
If you are baby-wearing or carrying, make sure your child’s head is above the fabric. Be sure that her nose and mouth are not blocked. You should be able to see her face. If your child falls asleep in a sitting device, move him to an appropriate flat surface as soon as it is safe to do so.
Devices like car seats should not be placed on a mattress or any other elevated surface. Additionally, do not leave infants unattended in them. Never leave your child unbuckled or partially buckled in ANY device that uses straps.
The AAP recommends breastfeeding or feeding with expressed milk exclusively for the first 6 months. Breastfeeding has been associated with decreased risk for SIDS. Exclusive breastfeeding has shown the highest protective effect. However any amount of breastfeeding is reported to be more protective than none.
I want to take a moment to comment on this particular recommendation and emphasize that IT IS OK IF YOU CANNOT BREASTFEED OR PUMP. Some babies can’t breastfeed. Some mothers struggle to or can’t breastfeed or pump.
By the time my twins were 2 months old I had to switch to formula for them. They are perfectly fine. It’s not the end of the world and remember that fed is best. If you are able to breastfeed, GREAT – if not, don’t stress about it. Trust me, it’s not worth feeling guilty about.
4. START THEM IN YOUR BEDROOM
The AAP states that the risk of SIDS can drop up to 50% when your child sleeps on a separate surface in the same room as you (so nearby, but NOT bedsharing with you). The recommendations state to room-share for the first 6 months at least (because the rate of SIDS is highest in this time frame), and ideally for the first year.
The AAP does not have enough evidence at this time to recommend for or against products that are supposedly designed to make bed-sharing “safe”. We don’t know yet if they decrease SIDS risk or if they actually are safe products.
For overnight feedings, the AAP recommends bringing your child to your bed rather than a couch or armchair if there is any risk of YOU falling asleep during the feed. Infants that fall asleep in those places are at EXTREMELY HIGH risk of death.
When bringing your child into your bed, the AAP recommends to remove pillows, blankets, sheets, or any other similar items from the area. Many infants that die from SIDS are found with bedding covering their heads. If you fall asleep while feeding your child, return her to her separate space as soon as you wake up.
Let’s get real for a moment. Is it very likely that you will be able to wait until your child is 1 year old to move her to her own room? Honestly, probably not.
When I spoke with my pediatrician about it, he said that if you wait much past 3 months then everyone’s sleep starts to get more disturbed because your child is much more aware of you and your movements. She might not be able to sleep well if you are in the room with her.
So it’s up to you to weigh the risks versus benefits of following this recommendation to the letter. Personally, I did move my twins into their own room at around the 3 month mark and it seemed to work very well for their quality of sleep.
5. REMOVE ALL SOFT OBJECTS AND LOOSE BEDDING
These types of items could end up covering your child’s nose and mouth and obstruct his breathing. This means no pillows, no blankets, no stuffed animals, and no crib bumpers!
Bumpers were originally marketed to prevent infants from getting their heads stuck in the cribs. Cribs are now manufactured with slats too small for this to happen, so there is more risk to them than benefit.
I worried about my kids bumping their heads on the hard crib sides or getting arms and legs stuck in the slats, so we bought the “breathable”bumpers that are supposedly safer. We ended up taking them off because the bumpers actually caused more problems with getting feet stuck in them. The head bumping thing was never an issue – my daughter (who is now almost 2) prefers to fall asleep with her head shoved up against the side of the crib. She has been that way since she was able to start moving around her bed. If I have another child, I will be completely skipping the bumper pads.
The current guidelines do not differentiate between traditional and newer “breathable” types, so I take this to mean they do not recommend using any of them; realistically they could still pose a risk.
How do I make sure my infant stays warm at night without using bedding? The preference is for products like wearable blankets. Because they are not loose, it’s much less likely that they will wind up covering your child’s face or trapping him in a position in which he can’t breathe (as long as you choose a properly fitted one!)
I waited until well after my childrens’ first birthday to let them bring stuffed animals to bed with them, and they still use wearable blankets at night (they are indeed available in toddler sizes). Let’s be honest – when they are that young even if you wanted to let them use a loose blanket at night it would never stay on. You’d just end up having to go to their rooms any time they wake up at night because they are cold and either can’t reach or figure out how to put on their blankets. I plan on using them as long as my kids fit in them.
6. CONSIDER PACIFIERS
No one really knows why, but studies have shown that the use of pacifiers at bedtime are associated with a decreased rate of SIDS. This is true even if it drops out of the baby’s mouth while asleep, meaning you don’t have to pop it back in every time it falls out! Just offer it when laying your child down to sleep. If she refuses, don’t force it, you can try again another time.
The AAP recommends using just plain, loose pacifiers. Don’t use ones that hang around baby’s neck or clip to clothing because they pose a strangulation risk. This would also mean that those cute pacifiers with stuffed animals attached are not recommended.
If you are breastfeeding your child, you should wait to offer a pacifier until you and your baby have fully gotten the hang of it.
7. SMOKE EXPOSURE, ALCOHOL, AND DRUG USE
A baby whose mother either smoked, drank alcohol, or used illegal drugs while pregnant is at higher risk for SIDS. Secondhand smoke exposure after birth also increases risk.
Babies are at even HIGHER risk if they share a bed with someone who either smokes, drinks alcohol, or uses drugs. Interestingly, even if the adult smoker does not actually smoke in bed while bed-sharing with the infant, the baby is still more likely to die from SIDS.
8. PREVENT OVERHEATING
Infants who get too hot are at higher risk for SIDS. The general recommendation the AAP provides is to dress your infant appropriately to the environment, plus no more than 1 extra layer compared to what you yourself would wear in that situation.
Signs of overheating to look for would include sweating or a chest that is hot to the touch.
9. PRENATAL CARE AND IMMUNIZATIONS
Both regular prenatal care for the mother and the recommended vaccinations for infants are linked to lower risk of SIDS.
10. COMMERCIAL DEVICES AND HOME MONITORS
There are various products on the market that may claim to “reduce the risk of SIDS”. There is currently no evidence that any of these reduce risk. In fact, some of them go against the current recommendations provided (such as wedges and positioners).
If you want more information about the safety of a certain product, please visit the Consumer Product Safety Commission website.
Some doctors may prescribe for a home cardio-respiratory monitor that follows an infant’s vital signs to detect heart and breathing abnormalities. Unfortunately these monitors and other similar commercial devices have not been shown to decrease SIDS risk.
Swaddling can be super helpful in calming your baby. Be careful though, because infants that end up on their tummies while swaddled are at very high risk of death.
If you swaddle your child, follow these recommendations:
- Always place him on his back while swaddled.
- Make sure the swaddle is snug at the chest to keep it in place, but loose around the hips and knees to prevent hip problems.
- Once your baby starts attempting to roll, stop swaddling.
SAFE SLEEP HIGHLIGHTS
What I have attempted to summarize for you here is a very long list of guidelines! Remember that this list basically outlines all the evidence we have at this time as to what factors increase or decrease risk of SIDS.
You may not be able to follow every single recommendation that the AAP made. Like I shared above, I moved my kids to their own room at 3 months, and I did not breastfeed past 2 months.
Use this information to help you make decisions on how you can best reduce the risk of serious harm coming to your child while she is sleeping.
Make sure to educate anyone who takes care of your child to follow that same practices that you do. Some of the most important precautions from this list you can take are to always lay your baby down on her back on a firm, flat surface that is free of any loose or soft bedding or other items.
HELP SPREAD THE WORD
We’ve come a long way since the early 1990’s in decreasing the rates of sleep-related deaths in infants. We can still do more, though.
Education about safe sleep practices is critical. New mothers may be getting advice from older generations that followed different practices. It’s basically only been ONE generation since parents were advised to lay baby down on his stomach to sleep.
Please take a minute to share this post, or any of the resources below that you find helpful, so that knowledge of safe sleep practices can continue to reach new or expecting mothers.
If you are interested in more details or information on safe sleep practices, check out the following websites:
Official 2016 recommendations by the American Academy of Pediatrics – This document goes into much further detail than the summary I have provided here.
Safe to Sleep – This is the official Safe to Sleep campaign website, run by the National Institute of Child Health and Human Development (NICHD). You can find more information on the history of the public education campaign and many printable materials such as brochures, handouts, and booklets.
Consumer Product and Safety Commission – This is the official Consumer Product and Safety Commission website. Here you can view product standards and search for recalls.
Reducing the Risk of SIDS and SUID in Early Education and Child Care – This is a FREE online course on reducing SIDS risk, put together by the American Academy of Pediatrics. ANYONE can take it!
CDC SIDS Data – Visit this page on the CDC website for current data on SIDS and SUID in the United States.