Frequently Asked Questions
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The answers to these questions are based on the American Academy of Pediatrics Policy Statement - SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment.
Why is it recommended that babies sleep on their back?
Babies should be placed on their backs every time they sleep until 1 year of age, because:
- Babies sleeping on their stomachs have a much greater risk of sleep-related death.
- Stomach sleeping increases the risk of rebreathing the same air that is under the baby’s face. When this happens, a baby who does not rouse and move his or her head can end up with too much exhaled carbon dioxide and not enough oxygen in their blood, a condition that can be fatal.
- Sleeping on the stomach increases a baby’s risk of becoming overheated, as not as much heat is given off in the stomach-sleeping position. Overheating has been associated with greater risk for unexpected infant death.
- In babies 2 to 3 months old, stomach sleeping changes how the nervous system controls the cardiovascular system (how the heart functions) during sleep and can result in a decrease in oxygen to the brain.
What should parents do when their baby begins to roll over?
Rolling over is an important and natural part of a baby's growth. Most babies start rolling over on their own around 4 to 6 months of age, but some start much earlier. Once a baby can roll from his back to his stomach and from his stomach to his back, he can be allowed to remain in the sleep position he moves to on his own. To reduce the risk of sleep-related infant death, it is important that baby starts every sleep time on his back and that there are no soft objects, toys, crib bumpers, or loose bedding under baby, over baby, or anywhere in baby's sleep area.
Are there risks associated with swaddling? When should swaddling be discontinued?
Yes. There are risks associated with swaddling. They include:
- Swaddling too tightly or with the legs extended and adducted (when the baby’s legs are straight and tight next to each other) can cause developmental dysplasia of the hips (an abnormal formation where the top of the thigh bone is not held firmly in the socket of the hip). When swaddled, baby’s hips and legs should be able to move.
- When the swaddling blanket is added to clothing the infant is already wearing, swaddling can result in the baby becoming overheated.
- If baby is swaddled with a blanket, it could come loose and become a suffocation hazard.
- Tight swaddling can make it hard for baby to breathe. You should be able to get at least two fingers between the baby’s chest and the swaddling blanket.
- Accidental deaths have occurred when swaddled infants are placed on their stomach or when they roll to their stomach. (An infant may roll onto her stomach even if not regularly rolling.) Swaddled infants on their stomachs are unable to use their arms or upper bodies to push themselves off the mattress or change their head and body position if they are in a position that could cause suffocation.
If parents decide to swaddle their baby, they should always place baby fully on his back to sleep. Swaddling should be stopped by 6 to 8 weeks of age or when baby makes any signs of attempting to roll over.
Please note, there is no evidence that swaddling reduces the risk of sleep-related infant death.
Should a baby still be placed on his back to sleep if he spits up often or has reflux or GERD?
Some babies have GER (also known as reflux) or GERD. GER (gastroesophageal reflux) is normal spit up. GERD (gastroesophageal reflux disease) is when it progresses to where the infant is having symptoms such as poor weight gain related to the reflux. This requires a medical diagnosis and is very rare in babies under age 1.
The American Academy of Pediatrics, in concurrence with the North American Society for Pediatric Gastroenterology and Nutrition, indicate that the risk of SIDS and sleep-related infant death outweighs any benefit of side or stomach sleeping to treat GER. Therefore, for most infants, back sleeping is recommended. If a baby spits up while lying on her back, it will not cause her to choke. The baby will cough to clear her airway and/or the spit up will dribble out the side of her mouth.
Elevating the head of infant’s crib, or having baby sleep in a car seat or swing, are ineffective in reducing reflux and are not recommended. Elevating the head of the crib may result in the infant sliding to the foot of the crib into a position that may compromise breathing.
Parents can do the following to help reduce how much a baby spits up:
- Hold baby upright after feedings.
- Limiting the baby’s activity after feedings.
- Burp baby frequently during and after feedings.
- Provide more frequent, smaller feedings.
- Reduce a baby’s exposure to smoke in the home.
How can you breastfeed and practice safe sleep?
Breastfeeding does provide the best nutrition for baby, builds the immune system and promotes bonding, as well as many other health benefits. Breastfeeding also reduces the risk of sleep-related infant death.
Before a mother starts breastfeeding her baby, she should think about how tired she is. If there's even a slight chance she may fall asleep while feeding, she should avoid couches and armchairs. These surfaces can be very dangerous places for babies, especially when adults fall asleep with infants while on them. Mothers who bring the baby into an adult bed for feeding or comforting should remove all soft items and bedding from the area, especially if there’s any chance that she may fall asleep. If she accidentally falls asleep while feeding or comforting baby in the adult bed, the mother should put the baby back into his or her separate sleep space as soon as she wakes up. Mothers could set an alarm to wake her up or have a support person available in case she accidentally falls asleep. Watch this video from the Safe to Sleep® campaign to learn more.
When can you give babies blankets/stuffed animals to sleep with?
Babies should have nothing in their sleep area until they are at least one year of age.
Note: Research has not shown us when it's 100% safe to have these objects in the crib; however, most experts agree that these objects pose little risk to healthy babies after 12 months of age.
Can babies sleep in swings, bouncy seats, or other sitting devices?
Babies should not be allowed to sleep in an environment that is not a safety approved crib, play yard, pack and play, or bassinet.
Babies airways are so tiny that even slight changes in angle can compromise breathing. Some babies have suffocated in these locations when their airways have been constricted or when their face is pressed against the device, blanket, or other item. Babies have also suffocated when they have turned over or moved unexpectedly in one of these environments and they are unable to breathe.
Anytime a baby is placed in one of these devices, they should be properly strapped in. If baby falls asleep in one of these places, he or she should be moved to a crib or other appropriate flat surface as soon as it is safe and practical. Learn more about unsafe sleep spaces.
Why don't babies choke when they are on their back?
Babies are actually safer on their backs. When a baby is on his back, the air tube (trachea) is on top of the esophagus (the tube that carries food). If a baby spits up while on his back, the food and fluid run back into the stomach and not to the lungs. When a baby is on his stomach, the esophagus (or food tube) is on top of the trachea and any food or fluid that is regurgitated or refluxed can more easily pool at the opening of the trachea, making it possible for the baby to aspirate or choke. The following images and video help illustrate this.
Image from National Institute of Child Health and Human Development Safe to Sleep® Campaign, available at: www.nichd.nih.gov/sts/news/downloadable/Pages/default.aspx
How Do I Know If It's Safe for Sleep?
What should providers tell caregivers about falling asleep while feeding their baby?
Parents may accidentally fall asleep while the baby is still in bed with them. This situation can be dangerous, as there is often loose or soft bedding (such as blankets or pillows) in the bed. Babies can also fall into and become wedged in the space between the adult mattress and the wall or nearby furniture. Parents who bring the baby into an adult bed for feeding or comforting should remove all soft items and bedding from the area, especially if there’s any chance that the caregiver may fall asleep. Parents should put their baby back into his or her separate sleep space when the baby or parent is ready to go to sleep. If the parent accidentally falls asleep while feeding or comforting baby in the adult bed, the parent should put the baby back into his or her separate sleep space as soon as the parent wakes up. Parents could set an alarm to wake them up or have a support person available in case they accidentally fall asleep. Watch this video from the Safe to Sleep® campaign to learn more.
What is a safe sleep space?
A firm, flat sleep area is safest for infants. A crib, bassinet, portable crib, or play yard that follows the safety standards of the Consumer Product Safety Commission (CPSC) is recommended. The mattress should be covered by a tightly-fitted sheet with no other bedding or soft items in the sleep area. Review the Safe Sleep Steps for more information on what a safe sleep environment looks like.
What should baby wear to sleep?
Dress baby appropriately for the environment, with no greater than one layer of clothing more than an adult would wear to be comfortable. Keep the room at a temperature that is comfortable for an adult. Babies should not wear hats while sleeping.
For more information:
American Academy of Pediatrics SIDS and Other Sleep-Related Infant Deaths:
Updated 2016 Recommendations for a Safe Infant Sleeping Environment