Safe-Sleep Alert

by Rachelle Vander Schaaf

Safe-Sleep Alert

Safe-sleep products for babies have become big business. A range of items—from mattress pads that fight germs to a slew of gadgets that purport to help prevent sudden infant death syndrome (SIDS)—are being sold in the name of child safety.

Fortunately, the most important precautions are also the simplest: A baby should be put to sleep on her back in a safe crib, with a firm mattress and a fitted sheet and no soft bedding or plush toys. (In some cases, as when a baby has severe gastroesophageal reflux, doctors may recommend that she be put on her stomach.) But will it help to go beyond the basics? Can these safety devices really offer extra protection? How can you tell?

We asked medical experts for their assessment of some of the current products and asked how they would advise parents to outfit a safe sleeping space for their newborn. Their recommendations:


Crib basics

Before you’ve even considered any safe-sleep product, you face a bigger choice: which crib to buy or borrow. The most important factor is the manufacture date. All cribs sold in the U.S. since 1990 must adhere to strict federal safety standards set by the Consumer Product Safety Commission (CPSC). Pre-1990 pieces and yard-sale bargains may have dangerous designs or broken parts that can pose a safety risk. Cribs made before 1990 still cause 9,300 injuries and 50 deaths every year, more than any other nursery product.

“The safest place for a baby to sleep is in a well-designed, modern crib with a mattress that fits tightly,” says Bradley Thach, M.D., professor of pediatrics at Washington University School of Medicine. When you are purchasing a crib, be sure to look for:

  • Screws, brackets and joints that are tightly in place and intact.
  • A mattress that fits snugly, so the baby can’t become trapped between it and the sides of the crib.
  • Slats no more than 2 38 inches apart-the width of a soft-drink can. A wider space is enough to allow a baby to slide through and get stuck.
  • Corner posts that don’t extend more than 1/16 of an inch, so clothing can’t get snagged.
  • A headboard and footboard without decorative cutouts, which could trap a baby’s head.


A healthy mattress?

Once you’ve gotten a crib, you’ll be buying a mattress, a pad and sheets. Should you pay extra for those with “breathable” surfaces, which supposedly help to prevent the baby from suffocating by “rebreathing” exhaled carbon dioxide? The concept: In a ventilated surface, fresh air should continually flow to a facedown baby through holes and special channels. “Rebreathing is one of the leading theories about what causes SIDS, and manufacturers have latched on to it,”says John Kattwinkel, M.D., chair of the American Academy of Pediatrics’ (AAP) task force on infant sleep position and SIDS.

Experts on SIDS express concern that such products may undercut the “Back to Sleep” message. One product, Baby Air, claims that its mattress allows a baby “to sleep safely in any position.” That’s misleading, says Dr. Kattwinkel: “Back-sleeping is the best known way to lower the risk of SIDS.”

What if your baby turns over on his stomach? Not likely, Dr. Kattwinkel says. Putting young infants on their back to sleep is effective because they stay put. By the time they’re able to roll onto their stomach on their own—usually at 6 months—infants are past the peak risk period for SIDS (3 to 5 months). But since it’s a possibility that a back sleeper can get tangled in sheets that could cover his face, isn’t a breathable system a form of insurance? “Research indicates that these products won’t prevent rebreathing,” says James Kemp, M.D., assistant professor of pediatrics at St. Louis University School of Medicine. He recently conducted the first independent study comparing five of these ventilated surfaces with two standard surfaces. Dr. Kemp used an infant mannequin designed to measure the amount of carbon dioxide in a baby’s face, and tested it both in facedown and on-its-back positions. His conclusion: Four of the tested systems—Baby Air, Breathe Easy, Bumpa Bed and Sleep Guardian—caused more carbon dioxide to be trapped in the mannequin’s face, compared with back sleeping.

“Most items said to prevent rebreathing do little to reduce, or may worsen, carbon dioxide trapping,” says Dr. Kemp. “I wouldn’t recommend any of these for infants who might turn facedown.” One possible reason, he notes: Many of the “breathable” materials may have been originally designed for clothing, so they actually keep air close to the skin.

The manufacturers of these products agree that babies should be placed on their back when put to sleep. However, they maintain that the products have been tested and shown to provide a breathable surface, should infants roll over. Still, the only product Dr. Kemp judged effective—comparable to a baby sleeping on his back on a standard mattress—was the Halo Sleep System, a mattress that contains a fan inside that gently blows exhaled air away from a baby’s face. But it’s pricey: It costs $200 for the mattress and $30 for a ventilated sheet and mattress pad.

However, Dr. Kemp and other experts assert that the best thing to do is to put a baby on his back on a firm mattress, no matter which mattress you choose.


Positioning props

You faithfully place your baby on her back, but you’re concerned that she won’t stay put. Or she seems more comfortable on her side. “Provided a pediatrician okays it, side sleeping is a legitimate alternative to the back,” says Dr. Kattwinkel. “But SIDS risk does increase slightly on the side, probably because it’s an unstable position and the infant could roll to the stomach. When she is side-sleeping, make sure to position the baby’s lower arm forward; this will help prevent her from rolling over.”

There are a variety of pads designed to hold your infant in place, on her side or back, including the Curved Side ‘N Back Sleeper by Graco, the Airflow Sleep Positioner by the First Years, and the Safe & Sound Sleep System by Basic Comfort (ranging from $10 to $19).

One concern: Theoretically, using one of these could be harmful if a baby wiggles away and ends up between the pad and the crib, entrapping the head, says pediatric pulmonologist Gerald Strope, M.D., associate professor of pediatrics at Eastern Virginia Medical School. The bottom line, says Dr. Strope: “The more stuff you put in the crib, the more opportunity there is for that baby to get into trouble.” Even a rolled-up towel or receiving blanket used for positioning could unroll and get tangled around the baby. Manufacturers for positioning products advise you remove them from the crib once a baby can turn over on her own.


Bacteria barriers

If your baby is at risk of developing asthma or allergies—she gets eczema, or others in the family have respiratory problems—you may be interested in products like the MicroSafe antimicrobial pad ($20), which claims to hinder the growth of bacteria, mold and mildew. Its maker contends that when the mattress or sheet gets wet, its product will help prevent the growth of fungi.

But hypoallergenic bedding likely offers no advantage over the standard kind, says Michelle Lierl, M.D., associate professor in clinical pediatrics at Children’s Hospital Medical Center, in Cincinnati: “A regular crib mattress already protects a child with allergies because it’s encased in vinyl, so dust mites, the most common irritant, can’t get in.” As for cloth pads and sheets, she says, “the best way to get rid of allergens is to launder the bedclothes frequently in hot water.”



If your baby has an earache or bronchial congestion, your pediatrician may recommend that you elevate his head. One way to achieve this safely is to position a pillow under the mattress-never on top of it, because your baby’s head could get wedged between the pillow and the crib,

increasing the risk of suffocation. Other alternatives include products such as Cribblox ($14), which will lift the crib legs off the floor at one end, or a pad like the Safe Lift Crib Wedge ($11) or Perfectly Safe Crib Wedge ($14), which, like a pillow, should be used under the sheet or mattress.

“Elevating your baby’s head can help him breathe better,” says Dr. Lierl. But don’t elevate too much, or he’ll simply slide to the foot of the crib.


Ties that bind

Frequent laundering can shrink a sheet and weaken its elastic, so that it no longer tucks tightly beneath the mattress; if the sheet pulls up, it could entangle a baby. Since 1984, three such fatal incidents have been reported to the CPSC.

One solution: the American Baby Company’s Safety Crib Sheet ($15), which ties to crib rails so it stays in place. “It’s a low-but real-risk, and a tie-on sheet may safely address the problem,” says Mark Stegelman, M.D., a pediatrician at Egleston Children’s Hospital, in Atlanta. “Just make sure that the strings can’t come loose and pose another strangulation hazard.” Ties should be no more than six inches long. You can also simply check the sheets for a secure fit each time you make up the crib.


High-tech monitors

Many parents use monitors to hear the quiet that signals baby is snoozing. But if the sound of silence leaves you anxious, you might be intrigued by the Angelcare Sound Monitor & Movement Reassurance System ($99). This device is designed to pick up slight motions and sounds your baby may make while sleeping; a sensor pad placed under the crib mattress triggers an alarm if a baby’s movements have stopped for more than 20 seconds.

If your infant is truly at risk for serious breathing problems, however, your pediatrician may prescribe an apnea monitor, which sounds an alarm when an infant stops breathing. (Such medical devices rent for about $425 a month.) For these children, “anything else isn’t reliable enough,” says Dr. Stegelman. Yet even with apnea monitors, there’s still a risk of SIDS.

For a healthy baby, monitors do no harm, as long as you stick to the “Back to Sleep” rule, says Dr. Stegelman. However, he notes, a false alarm could disrupt everyone’s sleep.

Do you need such safety products? Perhaps you’ll sleep better knowing that your baby will breathe more easily if she turns over on her stomach, or that you’ll be awakened if her motions or breathing stops. Only you can decide if these safety products are worth the money, but experts feel that they’re not essential.

“Putting a baby to sleep on her back in a safe sleeping space should be the number-one priority,”says Susan Pollack, M.D., a member of the AAP’s committee on injury and poison prevention. “You can spend a lot of money on accessories, but all you really need are the basics: a safe crib, a firm mattress and a tightly fitted sheet.”