How You Can Protect Your Baby from SIDS

Published with input from Maureen Plummer, pediatric sleep consultant certified by the Family Sleep Institute and founder of Sweet Surrender Pediatric Sleep Consultants 

About 3,500 babies die in their sleep each year at the hands of unseen and often unknown killers. One of those killers is commonly called SIDS, or Sudden Infant Death Syndrome. More infants die from SIDS in their first year of life than from any other cause of death, yet many questions about this mysterious killer remain.

SIDS describes any death of an infant less than one year old that occurs for no apparent reason after a full investigation has been completed. Most SIDS deaths occur between the ages of one and four months, and boys appear to be at greater risk than girls. According to the Mayo Clinic, there does not appear to be one single cause of SIDS. Many researchers believe that SIDS is associated with a hidden abnormality in the brain that renders a baby unable to rouse from sleep or detect low levels of oxygen and a build-up of carbon dioxide in the blood. 

But that doesn’t mean all babies with such abnormalities will die from SIDS. Other risk factors are often present when a baby’s death is determined to result from SIDS. As a result, the Triple-Risk Model has been offered as a means of explaining how SIDS occurs.

SIDS may occur when the following three conditions exist at the same time.

1. Vulnerable Infant. The infant has an underlying abnormality that makes them unable to respond to low oxygen or high carbon dioxide levels. Other vulnerabilities include undiagnosed heart defects, infections, and other hidden yet identifiable factors. 
2. Outside Stressor(s). The infant is exposed to a suffocation or asphyxiation risk factor, such as sleeping on their tummy or having their head covered by a blanket.
3. Critical Developmental Period. These conditions occur in the first six months of life when the baby is in the most vulnerable stage of development.

Knowledge Gives You Power over SIDS

As researchers learn more about babies’ early brain development and the role it plays in their sleeping and breathing patterns, the number of SIDS cases—unexplained deaths—has declined. Upon investigation, coroners and physicians have been able to identify previously undetected physical vulnerabilities that have contributed to the deaths. 

Further driving down the incidence of SIDS is widespread education of parents about the risk factors that can lead to death by suffocation or asphyxiation either by themselves or in combination with certain developmental abnormalities. According to Dr. Rachel Moon, who chairs the American Academy of Pediatrics Task Force on SIDS, regions around the country are seeing dramatic drops in the number of true SIDS cases because most unexpected infant deaths have occurred in unsafe sleep environments. 

Moon says, “These are all cases that could have been prevented.” 

AAP’s Safe to Sleep® Campaign

It wasn’t too long ago when many unexplained infant deaths were simply chalked up to tragic and unavoidable misfortune. But newer research into babies’ physical development and the best sleep environments for them has taken away some of the mystery of babies dying in their sleep. More importantly, such research has helped health officials develop guidelines for keeping babies safe while they sleep. 

The American Academy of Pediatrics (AAP) leads the effort in educating parents about ways to reduce the risk of death by SIDS with a list of Safe to Sleep® practices for parents. Originally called the Back to Sleep campaign when it was launched in 1994, the Safe to Sleep® guidelines have been remarkably successful in reducing the number of infant deaths by SIDS. Since the campaign started, the percentage of babies being placed on their backs to sleep has risen while at the same time, the rate of SIDs deaths has declined by more than 50%. 

Because the AAP does not consistently offer explanations for their guidelines, we asked a pediatric sleep expert to help flesh out the guidelines and explain how parents can reduce the risk of SIDS in their homes. 

Maureen Plummer, founder of Sweet Surrender Pediatric Sleep Consultants, LLC, is a pediatric sleep consultant certified by the Family Sleep Institute, which has set the standard for best practices in the field worldwide. She joined me to explain some of the more challenging safe sleep guidelines and share some of her experiences coaching parents about safe and restful sleep for their babies. 

The New AAP Safe to Sleep® Recommendations

The most recent guidelines for safe sleep can be summarized as public health officials in Baltimore have done: Alone. Back. Crib. (also known as the Safe Sleep ABCs.)

(The recommendations for sleep environment and sleep position are for infants up to one year of age unless otherwise specified.)

1. Baby should always be placed on their back to sleep for every sleep occasion. 

Parents should take care to inform all caregivers, including daycare providers, of this most important safe sleep practice. Grandparents need to be reminded when they care for grandchildren because the AAP guidelines have changed since many of them raised their children. 

Pediatric sleep consultant Maureen Plummer points out that the supine position (on baby’s back) is the safest because

• It promotes baby’s easy access to oxygen by keeping their face and nose away from the bed surface.
• It keeps baby’s face away from the mattress surface which may contain microbes that could interfere with breathing.

You may have heard that this position places babies at risk for choking and aspiration, especially babies with gastric reflux disorder. However, the AAP and the American Society of Pediatric Gastroenterology and Nutrition agree that the risk of SIDS outweighs the benefit of tummy or side sleeping for infants with gastric reflux. 

Once a baby is able to roll from their back to their tummy and from their tummy to their back (as observed during wakeful tummy time), they can be allowed to remain in the sleep position they assume after falling asleep. You should still place your baby on their back in their crib to sleep until they are one year old. 

2. Baby should always sleep on a firm sleep surface.

Firm sleep surfaces include the following products provided they conform to the safety standards of the Consumer Product Safety Commission (CPSC).

• Cribs 
• Bassinets
• Portable cribs
• Play yard

Baby should never sleep in their parents’ bed either alone or with their parents. *Sleeping with one or both parents could result in the baby becoming trapped under the weight of their parent, with their nose or mouth against their parent, or wedged beneath a pillow, resulting in suffocation. Surfaces that are not sufficiently firm may conform to your baby’s head, creating an indentation that poses a suffocation or asphyxiation risk for the baby. 

In-bed sleepers—inserts laid on parents’ bed—currently are not regulated by CPSC standards and, therefore, are not recommended. Sitting devices such as car seats, strollers, swings, infant carriers, and infant slings should not be used for sleeping. 

Maureen Plummer says that in her practice, she finds parents struggle to comply with this guideline—once their babies fall asleep in whatever device they are in, parents are reluctant to move them to their cribs. But, she says, “the chances of a baby slumping in that position and blocking their airways are real. Thus, on their back, in the crib is really the only safe option.” 

If your baby falls asleep somewhere other than their crib, they should be moved to their crib or another flat, firm, and CPSC-approved sleep surface as soon as possible. Couches and armchairs are especially dangerous sleep surfaces for your baby because they are softer than recommended and pose a risk of entrapping your baby’s head in a suffocating position. 

*Bed sharing, room sharing, and independent sleeping. At the time of this publication, the AAP included a recommendation that baby sleep in parents’ room, close to parents’ bed on a separate safety-approved sleep surface, for at least the first six months up to a year, an arrangement known as room sharing. Plummer indicates that the AAP is likely to back away from this recommendation in their newest update of the Safe to Sleep® recommendations due out in 2021. 

According to Plummer, recent research has shown that the improved monitoring of baby’s breathing and general well-being while room sharing is outweighed by the impaired sleep quality for both baby and parents. In addition, according to the AAP, studies have shown that room sharing, which was intended as a safer alternative to bed-sharing, often led to bed-sharing anyway. 

In light of this new research, there is a renewed interest in teaching babies to sleep in their own rooms. A study published in Pediatrics showed that early independent sleepers (before four months of age) slept longer and for longer stretches than babies who slept in their parents’ room. According to Plummer, at nine months, these babies were better sleepers, not just compared to those who slept in their parents’ room but also to those who transitioned to their own rooms between four and nine months.  

She recommends the following strategies for encouraging your baby to sleep independently:

• Put the baby down drowsy but awake so they can learn to self-soothe.

• Watch babies for sleepy cues, and do not allow them to get overtired.
• Keep the sleep environment dark (blackout curtains are recommended).
• Use white noise machines to soothe the baby.

3. Baby’s sleep surface should be cleared of all soft or loose objects.

In her consultations at Sweet Surrender, Plummer finds that parents struggle to comply with this guideline, often allowing “loveys” and “sleep buddies” in their babies’ cribs. It may seem a bit sad to place your baby in an empty crib all alone, but this has more to do with your own preferences than with your baby’s. 

According to Plummer, babies “haven’t developed habits or preferences, so this is just what they know and quickly become accustomed to.” Furthermore, you are being a responsible parent by keeping them safe from dangers while they sleep. Loose bedding, blankets, bumper pads, and stuffed animals can all fall into positions that entrap or strangle baby or obstruct an infant’s nose and mouth, resulting in suffocation or asphyxiation. 

4. Avoid overheating and covering baby’s head while sleeping.   

Babies typically sleep hot, so their bedrooms should be kept cooler than you might prefer for daytime use. A good target temperature for sleeping is 68 degrees. Your baby should wear one more layer of clothing than an adult would wear in the same environment. 

Plummer recommends a sleep sac as an alternative to a loose blanket. She notes that sleep sacs are “an easy sell” because 

• They provide a feeling of security like being in the womb.
• They can be used for swaddling. 
• Sleep sacs help babies maintain the correct body temperature without becoming overheated from too many blankets. Babies are at higher risk of sleep-related death if they become overheated. 

Caregivers should check for signs of overheating such as sweating or infant’s chest feeling hot to the touch. 

5. Use swaddling judiciously. 

Swaddling may be used as a means of calming an infant and encouraging back sleeping. However, according to the AAP, “there is a high risk of death if a swaddled infant is placed in or rolls to the prone position [on their tummy].” Therefore, once an infant shows signs of trying to roll, even if unsuccessful, swaddling should be avoided. 

Plummer points out that sleep sacs are safer for swaddling than blankets, providing the baby with warmth and a sense of security while still allowing hip and leg movement.

6. Infants should be given ample opportunity for supervised tummy time while awake. 

Tummy time benefits your baby in two ways. Plummer notes that supervised tummy time “strengthens baby’s neck muscles, which may play a role in being able to get out of a position in which they cannot breathe.” The second benefit is to help prevent your baby from developing positional plagiocephaly, or flat head syndrome due to constant pressure in the same spot. 

If your baby constantly lies on their back for sleep and waking times, their head may develop a flat area while their bones are still soft and malleable. While it is never okay to allow your baby to sleep on their tummy or side until they can roll over, ample time off their back, either in your arms or lying on their tummy while awake and under supervision, is recommended to allow normal development of their skull.  

You can also help prevent a flattened head area by switching the direction you lay your baby in their crib (but always on their back) and avoiding excessive time in their car seat or carrier.

7. Breastfeeding is recommended.

Mothers are advised to exclusively breastfeed their babies at least until they reach six months of age, unless otherwise advised. Plummer says recent research shows that breastfed infants are about 60% less likely to die from SIDS than infants who receive no breast milk, but the exact reasons for this statistic remain unclear. 

Plummer suggests that these facts about breastfeeding surely play a role in protecting babies from SIDS:

• Breastfed infants may be more easily roused from sleep during the peak months of SIDS cases (2 – 4 months old), thus preventing them from sleeping through an episode of problematic breathing.
• Breast milk provides antibodies, specifically immunoglobulins, that may help protect babies from infection during that period. Illnesses like gastrointestinal and upper respiratory infections are more common in babies who are not breastfed, and these minor illnesses have frequently been associated with SIDS. 
• Breast milk provides optimal nutrition for brain development. This could help at-risk babies’ brains mature more quickly so that they have the normal response of gasping for air when they should.

8. Offer a pacifier at naptime and bedtime. 

Research has shown that pacifiers have a protective effect against SIDS, yet the protective mechanism is still unclear. Plummer believes that babies remain in a lighter state of sleep because of periodic movement while sucking on a pacifier. 

Lighter sleep means there is less chance for the baby to stop breathing. Furthermore, she agrees with another popular theory that pacifiers help babies to learn nasal breathing, which protects babies from infection better than mouth breathing. 

Parents should offer a pacifier when the baby is placed down for sleep, but it does not need to be reinserted if it falls out. Interestingly, the protective effect has been observed even if the pacifier falls out during sleep. However, if your baby refuses a pacifier, they should not be forced to accept it. 

Because of the risk of strangulation, pacifiers should not be attached to baby’s clothing during sleep. 

9. Infants should receive their routine vaccinations according to the recommendations of the AAP and the Centers for Disease Control.

Recent evidence suggests that vaccinations may offer some protection from the risk of death by SIDS. 

10. Pregnant women should obtain regular prenatal care. 

There is substantial evidence linking a lower risk of SIDS for infants to mothers who got routine prenatal care.  

11. Baby should not be exposed to smoke during pregnancy and after birth. 

Studies show that maternal smoking during pregnancy and second-hand smoke in a baby’s home are major risk factors for SIDS. Mothers should not smoke during pregnancy and tobacco smoke should not be allowed in the baby’s environment after birth. 

12. Avoid both alcohol and illicit drugs during pregnancy and after birth. 

Use of alcohol and illicit drugs during pregnancy has been associated with a high rate of SIDS.  After birth, use of alcohol and illicit drugs poses a particularly high risk of SIDS when combined with affected parents’ bed-sharing with their infant. 

13. Avoid using commercial devices that are inconsistent with Safe to Sleep® practices.

These include wedges and positioners used either in baby’s crib or in an adult’s bed. There is no evidence that any of these devices protect against SIDS regardless of claims the manufacturers might make. 

The most important safe sleep practices are that your baby sleeps alone, on their back, in their crib. (ABC).

14. Do not use SIDS prevention monitors as a strategy to reduce the risk of SIDS.

These monitors, also called cardiorespiratory monitors, measure the breathing and heart rate of sleeping infants. A monitor sounds an alarm if the baby’s breathing or heart rate falls below safe levels. 

However, according to Plummer, the name “SIDS prevention monitors” is “a misnomer if ever there was one. These monitors may alert parents to potentially dangerous situations, but by no means do they prevent SIDS. They may lead to a false sense of security, which leads a parent to be less vigilant about checking on the baby.” 

Furthermore, many of these devices have been shown to perform inconsistently. They may provide false negatives and overlook potential problems, as well as provide false positives, which create undue panic, anxiety, and unnecessary trips to the ER. 

A pediatrician may recommend the use of a cardiorespiratory monitor for some babies such as those who are premature or discharged from the hospital on oxygen. In these cases, parents should follow the advice of their baby’s doctor. 

For the average healthy baby, there is no benefit to using these devices. According to the Family Sleep Institute, “no product prevents SIDS.” Information about specific infant sleep products can be found on the CPSC website.

A baby’s and their parents’ need for sleep after birth is real. But so are the dangers associated with unsafe sleep environments. While some risk factors associated with SIDS may still be out of your control, a substantial number of them can be eliminated by following the AAP’s Safe to Sleep® recommendations.

Read More: How to Find Time to Sleep After Your Baby Is Born

You don’t have to trade your baby’s safety for a good night’s sleep. Adopting unsafe sleep practices for the sake of getting some desperately needed sleep could lead to a tragic outcome. A pediatric sleep consultant can help you establish a plan to help your baby and you get the sleep you all need while maintaining safe sleep practices. And that can make those first months and years of your baby’s life the most beautiful family time of all. 

Maureen Plummer is the founder of Sweet Surrender Sleep Consultants, LLC, and provides parents with support, consultation, and sleep plans to empower their children ages 4 months to 5 years old to get the best sleep possible.

Sources:

• Mayo Clinic: mayoclinic.org/diseases-conditions/sudden-infant-death-syndrome/symptoms-causes/syc-20352800
• National Institutes of Health: safetosleep.nichd.nih.gov/research/science/causes
• Pediatrics: pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938
• Family Sleep Institute: familysleepinstitute.com/2013/04/09/three-strategies-to-reduce-the-risk-of-sids-safe-to-sleep-campaign/
• Pediatrics: pediatrics.aappublications.org/content/early/2017/06/01/peds.2017-0122