Safer Sleep

by Marianne Neifert, M.d.

Safer Sleep

Probably the most common fear among new parents is Sudden Infant Death Syndrome (SIDS). Also known as "crib death," SIDS strikes about 1 in every 1,400 babies and refers to the sudden death of an infant in the first year of life for which no other explanation can be found. Since there are many ways to reduce the risk of SIDS, it's important to become informed so that you can protect your child and focus on enjoying new parenthood.

Who's at risk for SIDS?

Ninety percent of SIDS deaths occur within the first 6 months of life, with the peak age being 2 to 4 months. More boys are afflicted than girls, and African American and Native American infants have a higher rate of SIDS than Caucasian, Asian, or Hispanic infants. Because they are more likely to be placed on their stomach to sleep (a risk factor for SIDS), babies born to young mothers or less-educated mothers are also at a greater risk of SIDS. Premature and low birth weight babies, infants born to mothers with no or late prenatal care, or babies who are exposed to tobacco smoke are also at increased risk.

Getting "back" to sleep

Until recently, most doctors and nurses recommended that babies be placed on their tummy (the "prone" position) for sleep, as it was believed that this would make them less likely to choke if they spit up while sleeping. About 10 years ago, research conclusively showed that the prone sleeping position greatly increased a baby's risk for SIDS. In 1992, the American Academy of Pediatrics (AAP) recommended that babies be put to sleep on their back or on their side. After further studies showed that placing a baby to sleep on his side carried twice the SIDS risk of back sleeping, the AAP recommended in 1996 that babies be put to sleep on their back. A widespread "Back to Sleep" campaign has reduced the national incidence of SIDS by 40 percent over the past decade.

The threat of stomach sleeping is largely based on a "rebreathing" theory  — that if a baby sleeps on his stomach, he's more likely to sleep facedown or with part of his nose and mouth against the mattress. In this position he may inhale the same air that he's just exhaled and not get enough oxygen. The lack of oxygen should trigger a baby to wake up, but if for some reason it doesn't, the baby can suffocate. Prone sleeping also puts pressure on the jaw, narrowing the upper airway, which can interfere with breathing.

Although side sleeping is safer than stomach sleeping, it still carries a greater risk than back sleeping, probably because it's easy for babies to roll over to their tummy. If you use the side position, bring your baby's lower arm (the one on the side that she is resting on) in front of her body to reduce the chance that she'll roll to her tummy.

Safety strategies

You can reduce the risk of SIDS by creating a safe sleep environment for your child. Here's what to do:

  • Place your baby on his back to sleep in a crib that meets the standards of the Consumer Product Safety Commission for safe sleeping. (A doctor may recommend tummy sleeping for a few babies, such as those with rare complications of gastroesophageal reflux.)
  • Don't let your baby sleep on or near soft bedding. Use a firm crib mattress and don't place any blankets, comforters, quilts, stuffed toys, or pillows near your baby when she sleeps. Soft bedding can dangerously restrict the fresh air that your baby is able to breathe  — especially if she rolls onto her tummy or manages to burrow her face in the covers.
  • Be very careful about co-sleeping. Sleeping in a place other than an approved infant crib increases a baby's SIDS risk, and sharing a bed with family members can be dangerous for infants. A baby is more likely to roll onto her stomach on a soft adult mattress or to have her head sink into it. (For this reason, waterbeds are extremely dangerous for infants.) The close quarters also increase the chance that a parent could roll onto the baby; the blankets and pillows are a risk as well.

Nevertheless, many parents, especially breastfeeding mothers, bring their young infants into their bed. Bed-sharing has been shown to encourage breastfeeding, and recent studies show that co-sleeping can alter the sleep patterns of both mother and baby and increase infant arousals from sleep.

  • Don't overbundle your infant. Allowing infants to get too warm increases SIDS risk as overheating can cause babies to sleep deeply and fail to arouse normally. Keep her room at a temperature that is comfortable for a lightly clothed adult. Even though there isn't a blanket in the crib, your baby usually only needs one more layer than you do.
  • Educate your caregiver. Studies have shown that babies who are used to sleeping on their back are at particular risk for SIDS when placed on their stomach for sleep. This may explain why a larger-than-expected number of SIDS cases occur in childcare settings. Unaware of the current guidelines, older caretakers (such as grandmothers) may continue the sleeping practices they used when raising their own children. Remind all caregivers (including those at daycare) to put your baby "back" to sleep.
  • If you can, avoid buying a used crib mattress. A recent study confirmed the theory that infants who sleep on a mattress previously used by another child (particularly from another home) have a greater risk of SIDS, though the precise link is not understood. Talk to your doctor if you plan to use a crib mattress from another home.

Tummy time and other risk reducers

Risk reducers

In addition to creating a safe sleep environment, the following steps can lower SIDS risk by keeping your baby healthier.

  • Begin prenatal care early to help assure a healthy pregnancy and delivery of a full-term infant.
  • Breastfeed your baby if you can, and seek help for nursing problems since breastfed babies are at a lower risk for SIDS, for reasons that are not yet understood.
  • Don't smoke around your baby. Smoking during pregnancy or after giving birth increases a baby's risk of SIDS severalfold  — perhaps due to a chemical in environmental tobacco smoke (ETS) that interferes with infant breathing. A recent study found a significantly higher concentration of nicotine in the lungs of babies who succumbed to SIDS than infants who died from other causes. Babies and young children who are exposed to ETS also suffer more respiratory illnesses, ear infections, and other health problems.
  • Take care of infant illnesses. A disproportionate number of SIDS deaths involve infants who had a recent infection, such as a respiratory or intestinal illness. Be sure to keep all of your well-baby visits and stay on schedule for childhood vaccines. More SIDS deaths are also reported during fall and winter. For this reason, talk to your doctor when your baby is sick, and use a nasal aspirator to help keep her air passages clear when she has a cold.
The need for "tummy time"

While back sleeping is proven to reduce the risk of SIDS, it can affect a baby's head shape (making it flatter or lopsided) and temporarily delay motor milestones (such as rolling over or crawling) if a baby spends most of his day lying on his back. Make sure your baby spends some "tummy time" each day during periods of wakefulness and while being observed. This will help prevent flattening of the back of the head and strengthen arm and shoulder muscles. Another way to avoid a misshapen head: Alternate the way you place your baby in her crib each week so she will not always turn her head to the same side when she observes other people in the room.

Although SIDS represents a threat, the number of victims has declined as we have increased our knowledge about risk factors. You can take heart in knowing that, while it is not possible to eliminate the risk of SIDS, there are many ways to keep your baby safe.