Back to Sleep – Reduce the Risk of SIDS & Suffocation

It’s one of every parent’s worst nightmares but unfortunately, infants continue to die each year in the United States because of unsafe sleep environments. A recent study (February 2024) published in the journal Pediatrics and reported on in the American Academy of Pediatrics (AAP) News, discovered that about 60% of the 3,400 cases per year of sudden unexplained infant deaths in the United States occur in infants who share a sleep surface with a parent or other adult. The study describes these sleep surfaces as parental beds, couches, and chairs.

The good news is, however, that there are proven ways for parents to help their infant sleep safely. As a Pediatrician, I spend time in each infant well-child checkup to discuss safe sleep practices. These discussions are a vital part of primary prevention within the first six months of infancy, and cannot be ignored.

Safe sleep recommendations include the following:

Place your baby to sleep on his/her back every time. 

• Babies up to 1 year of age should always be placed on their back to sleep during naps and at night. If your baby is old enough to roll independently, he or she can be left in that position as long as the crib environment is safe – no blankets, crib bumpers, pillows, stuffed animals, or sleep position aides (wedges, etc). 
• If your baby falls asleep in a car seat, stroller, swing, infant carrier, or infant sling, baby should be moved to a firm sleep surface as soon as possible.
• Swaddling (wrapping a light blanket snuggly around a baby) may help calm a crying baby. If you swaddle your baby, be sure to place baby on his or her back to sleep. Stop swaddling your baby when he or she starts to roll. 

Place your baby to sleep on a firm sleep surface. 

• Your baby should have his or her her own, specific place to sleep.
• The crib, bassinet, portable crib, or play yard should meet current safety standards. Do not use a crib that is broken or missing parts or that has drop-side rails. For more information about crib safety standards, visit the Consumer Product Safety Commission Web site: https://www.cpsc.gov/SafeSleep
• Cover the mattress with a tight-fitting sheet. 
• Do not put blankets, pillows, wedges, or other sleep aides between the mattress and fitted sheet. 
• Never put your baby to sleep on a water bed, a cushion, swing, or Boppy. 

Keep the crib environment safe. 

• Pillows, quilts, comforters, crib bumper pads, and stuffed toys can become wedged against your baby’s face and create a risk of suffocation. 
• Remove all soft objects, loose bedding, or any objects that could increase the risk of entrapment, suffocation, or strangulation out of the crib. This is especially important when your infant begins to roll. 

Place your baby to sleep in the same room where you sleep but not the same bed. 

• Do this for at least 6 months, but it is recommended up to 1 year of age. Room-sharing decreases the risk of SIDS by as much as 50%.
• Keep the crib or bassinet within an arm’s reach of your bed at first. You can easily watch or breastfeed your baby by having your baby nearby. 
• Babies who sleep in the same bed as their parents are at higher risk of SIDS, suffocation, or strangulation. Parents can roll onto babies during sleep, or babies can get tangled in the sheets or blankets.

Breastfeed for as long as you can. This has been shown to help reduce the risk of SIDS.

• The American Academy of Pediatrics recommends breastfeeding as the sole source of nutrition for your baby for about 6 months. When you add solid foods to your baby’s diet, continue breastfeeding until at least 12 months. 

Schedule and go to all well-child visits. Your baby will receive important immunizations. 

• Recent evidence suggests that immunizations may have a protective effect against SIDS.

Keep your baby away from smokers and places where people smoke.

• If you smoke, try to quit. However, until you can quit, keep your car and home smoke-free. 
• Don’t smoke inside your home or car, and don’t smoke anywhere near your baby, even if you are outside. 
• Change your clothes or wear a smoking jacket that can be removed to avoid smoke exposure to your baby. 

Do not let your baby get too hot.

• Keep the room where your baby sleeps at a comfortable temperature. 
• In general, dress your baby in no more than one extra layer than you would wear. Your baby may be too hot if he/she is sweating or if his/her chest feels hot. 
• If you are worried that your baby is cold, use a wearable blanket, such as a sleeping sack, or warm sleeper that is the right size for your baby. These are made to cover the body and not the head.

Offer a pacifier at nap time and bedtime. 

• If you are breastfeeding, wait until breastfeeding is well established before offering a pacifier. This usually takes 3 to 4 weeks
• It’s OK if your baby doesn’t want to use a pacifier. You can try offering a pacifier again, but some babies don’t like to use pacifiers. 
• If the pacifier falls out after your baby falls asleep, you don’t have to put it back in.
• Do not use pacifiers that attach to infant clothing, as they can get tangled around baby’s neck.
• Do not use pacifiers that are attached to objects, such as stuffed toys and other items that may be a suffocation or choking risk.

Do not use home cardiorespiratory monitors to help reduce the risk of SIDS. 

• Home cardiorespiratory monitors can be helpful for babies with breathing or heart problems, but they have not been found to reduce the risk of SIDS. In fact, they often alarm unnecessarily and cause a lot of parental anxiety. Only use them if your baby’s doctor has recommended it. 

Do not use products that claim to reduce the risk of SIDS. 

• Products such as wedges, sleep positioners, special mattresses, and specialized sleep surfaces have not been shown to reduce the risk of SIDS. In addition, some infants have suffocated while using these products because of inclined sleep positioning and soft surfaces.

What about the risk of a flat spot on the back head?

It is true that we see many more cases of plagiocephaly – the flattening of the back of infants’ heads due to pressure – than we did before recommended that infants only sleep on their backs. However, plagiocephaly can be prevented or treated by increased tummy time during awake periods, and usually self-resolves. More severe cases can be treated with a helmet or a cranial band. Personally, I would rather treat plagiocephaly than grieve with parents over the death of an infant. 

Final thoughts

I originally posted this article in 2020, but it recently became apparent that it needed to be discussed again. The number of conversations I have recently had with parents asking about safe sleep practices and if they are truly necessary has been startling. This, combined with the study in Pediatrics last month solidified my determination to revisit the topic.

Suffocation deaths and SIDS are a possibility that no parent wants to think about, but they can be prevented to a certain extent. Following the safe Back to Sleep recommendations from the American Academy of Pediatrics can give parents the peace of mind that they are doing everything possible to keep their little ones safe while they are sleeping. 

Resources

Article in Pediatrics: https://publications.aap.org/pediatrics/article-abstract/153/3/e2023061984/196646/Characteristics-of-Sudden-Unexpected-Infant-Deaths?redirectedFrom=fulltext

AAP News Publication: https://publications.aap.org/aapnews/news/28213/Study-Most-infants-who-died-unexpectedly-had?searchresult=1?autologincheck=redirected

This article was originally published on September 8, 2020.

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