Safe Sleep

By Robert V. Hingre, M.D,  Assistant Professor of Pediatrics, Board Certified Neonatologist, Director of Newborn Medicine Teaching Program 

baby in crib on backEach year, Sudden Infant Death Syndrome (SIDS) claims the lives of more than 2,000 infants annually in the U.S.  The good news is that the death rate from SIDS has decreased by more than 50% since 1992, when the American Academy of Pediatrics (AAP) first made the controversial recommendation that infants be placed on their backs (in the supine position) for sleep.  This message was reinforced during a national educational program started in 1994, which was promoted as the “Back to Sleep” campaign.  The bad news is that SIDS rates have not experienced any further decline over the past decade, and we now need to focus on other risk factors to continue to lower SIDS risk and save the lives of current and future infants.

Since 2012 was the twentieth anniversary of the original AAP supine sleep recommendations, many organizations have tried to refocus their educational efforts on reinforcing additional (and expanded) safe sleep guidelines.  Parents and child care providers need to be ever vigilant about practicing safe sleep guidelines, and this is reinforced by the fact that currently 20% of SIDS cases occur when the infant is not in the care of one of the parents.  It is often a relative serving as an occasional babysitter who doesn’t know about safe sleep practices or someone who is using outdated information.  We now realize that such a practice is even more dangerous than ignoring the back to sleep recommendations entirely.  Occasional, or unaccustomed prone sleep on the abdomen places a young infant at an 18 times greater risk of SIDS, as they have not developed protective mechanisms for breathing while sleeping in a prone position.

The other troubling statistic is that while the number of SIDS deaths has been cut in half, infant deaths from Accidental Suffocation and Strangulation in Bed (ASSB) have quadrupled over this time period.  One of the most tragic scenarios leading to an infant death from ASSB is co-sleeping with a parent, and in many cases it is a mother who is exclusively breastfeeding her baby.  After analyzing all of the available research, the AAP has found that proximity sleeping/room sharing (having the infant in the same room as the parents) reduces the risk of SIDS by around 50%.  However, having the infant sleeping in the same bed alongside a full grown adult body is an extremely dangerous situation and the risks far outweigh any perceived benefits.  The infant can be brought into the bed for nursing, while mother remains awake, but he/she should be returned to their crib or bassinet to provide them with a separate, and protected sleeping space.

While there are numerous, and often costly, devices marketed to promote “safe co-sleeping”, the AAP has specifically stated there is no evidence that they have been proven to be truly safe. Whether these devices attach directly to the bed frame, or sit separately on the surface of the bed, we are told to assume that the risk of infant death from ASSB outweighs any convenience derived from parents sharing a sleep surface with their baby.

The other single most important factor that can further reduce the risk of SIDS is smoking cessation during pregnancy.  Researchers believe that around one-third of the current deaths from SIDS could be prevented if maternal smoking during pregnancy could somehow be eliminated.  This is now considered to be an extremely important area to focus our public health educational resources upon.   We also continue to recognize that exposure of infants to second hand smoke is a major risk factor for SIDS.

To ensure that an infant has a safe sleep environment, the AAP reminds parents of the following additional guidelines:

  1. infants should always be put to sleep supine (on their back) on a firm sleep surface until one year of age
  2. there should be no loose blankets, pillows, stuffed animals, or crib side bumpers
  3. avoid overheating and head covering during sleep
  4. cribs should have slats that are less than 2 3/8 inches apart, and those with drop-down sides are no longer considered safe, as they could lead to infant entrapment and suffocation
  5. sleep positioning devices (like wedges or side-sleep wraps) advertised to help infants with acid reflux and to prevent “flat head syndrome” are not recommended and have been linked to infant deaths during sleep
  6. when an older infant is developmentally able to roll from a supine to prone position, she/he does not have to be repositioned by parents

In addition to the aforementioned things to avoid, there are also two things that we should encourage to help lower an infant’s risk of SIDS.  Breastfeeding has long been recognized to have a protective effect, and recent estimates are that the risk of SIDS can be reduced by around 36% if an infant is breastfed after birth.  Exclusive breastfeeding for at least one month after birth has been found to reduce the risk of SIDS by more than 50%.

More recent information has brought the infant pacifier back into the limelight.  Regular pacifier use during sleep (with naps and at bedtime) has been shown in many different populations of infants to reduce the risk of SIDS by more than 50% – 60%.  The protective effect of the pacifier persists even after it falls out, so it does not need to be replaced by the parents.  To ensure that early pacifier use does not interfere with successful breastfeeding, many experts recommend delaying introduction of a pacifier until 2 to 4 weeks after birth, when a mother feels that successful nursing has been established.

It is now apparent that our educational message has to be expanded, and that it is not enough to simply preach “back to sleep” in an effort to reduce the risk of SIDS.  A number of other safe sleep recommendations should be promoted as part of our educational mission, if we are to try and further lower global SIDS rates and save additional lives of future infants. 

For more information, visit: A Parent’s Guide to Safe Sleep”.

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