Anna Briker, MD Candidate, and Karen Sheehan, MD, MPH
“Did you buckle your seatbelt?” This question is a common refrain for parents to their children, and rightly so. Motor vehicle crashes represent a major cause of death in children; in 2016, 1,233 children ages 14 and younger died in motor vehicle crashes1. Moreover, we know ways to prevent these deaths—seatbelts2.
Many would be surprised to hear about another, much less commonly discussed, yet similarly preventable cause of death in the pediatric population3. Each year, approximately 3,500 infants in the United States die from sleep-related deaths—an average of almost nine infants per day4. This statistic can be surprising and also incredibly scary for parents, especially since in the past, sleep-related infant deaths were viewed as a mystery5.
However, researchers now understand that sleep-related infant deaths are associated with several specific risk factors. Unfortunately, many parents receive conflicting information about safe sleep in infants6-8. The first step to keeping babies healthy involves learning about sleeping risk factors—and ways to avoid them.
In 2016, the American Academy of Pediatrics (AAP) released an updated policy statement with key recommendations for safe sleep. These guidelines should be followed as closely as possible every time an infant goes to sleep, including naptimes, until the baby reaches 1 year of age. If an infant falls asleep in a different environment or position (for example, in a car seat), it is important to move the infant to a safe sleep environment as soon as possible9.
- Infants should be placed on their back to sleep.
- Some parents worry that this position will predispose a child to choking6,10.It is important to note that infants have a lower risk of choking when placed on their back to sleep9.
- Infants should be put to sleep on a firm sleep surface covered by a fitted sheet. Infants should not sleep with bedding, stuffed animals, or bumper pads.
- Even though bumper pads and bedding are marketed for sleep7, they are inappropriate for infants and increase the risk of sleep-related death.
- Soft mattresses, couches, and other soft sleep surfaces—while comfortable for adults—increase the risk of suffocation for infants.
- Breastfeeding has been shown to decrease the risk of sleep-related infant death. It also offers many other protective health factors, such as fewer ear infections and other illnesses. For this reason, the AAP recommends exclusive breastfeeding for at least 6 months, with some breastfeeding better than none.
- Infants should sleep on a separate sleeping surface (i.e. crib or bassinette) in the parents’ bedroom.
- While infants should not share a bed with parents, it is best for them to be in the same room, to allow for monitoring and breastfeeding.
- The AAP writes: “The AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep. It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding. Therefore, no pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating should be in the bed. Parents should also follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens.”
- Smoke exposure during pregnancy and after birth increases the risk of sleep-related infant deaths.
- For reasons not entirely understood, smoking increases the risk of sleep-related deaths dramatically even if the parent does not smoke in bed.
- Consider using a pacifier at naptime and bedtime.
- Pacifier use seems to be protective against sleep-related infant death, even if the pacifier falls out after the baby falls asleep.
- Be sure not to use a pacifier that hangs around the baby’s neck.
- Alcohol and illicit drug use during pregnancy and after birth increases the risk of sleep-related infant deaths.
- Bedsharing with an infant after using alcohol or drugs is especially dangerous.
- Other recommendations include dressing infants appropriately for the environment (not overdressing them) and staying current with prenatal care before the infant’s birth and vaccinations after birth9.
Sadly, just as motor vehicle crashes can kill, so too can unsafe sleep environments. The best way to prepare is to know the guidelines, so that your baby—and you—can sleep soundly.
Want to see a safe sleep environment in action? The NIH website has a fun interactive online tool that reinforces some of the basics.
- Traffic Safety Facts. Washington, DC; 2018 4/2018. Report No.: DOT HS 812 491.
- Wolf LL, Chowdhury R, Tweed J, Vinson L, Losina E, Haider AH, et al. Factors Associated with Pediatric Mortality from Motor Vehicle Crashes in the United States: A State-Based Analysis. The Journal of Pediatrics. 2017;187:295-302.e3.
- Quinlan KP, Roehler DR, Silvestri J. Protecting infants from sleep-related deaths: A wake-up call. JAMA Pediatrics. 2018.
- Bombard JM, Kortsmit K, Warner L, Shapiro-Mendoza CK, Cox S, Kroelinger CD, et al. Vital Signs: Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015. Morbidity and Mortality Weekly Report. 2018;67(1):39-46.
- Garstang J, Griffiths F, Sidebotham P. Parental understanding and self-blame following sudden infant death: a mixed-methods study of bereaved parents; and professionals; experiences. BMJ Open. 2016;6(5).
- Moon RY, Hauck FR, Colson ER. Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change? Current Pediatric Reviews. 2016;12(1):67-75.
- Joyner BL, Gill-Bailey C, Moon RY. Infant Sleep Environments Depicted in Magazines Targeted to Women of Childbearing Age. Pediatrics. 2009;124(3):e416.
- Eisenberg SR, Bair-Merritt MH, Colson ER, Heeren TC, Geller NL, Corwin MJ. Maternal Report of Advice Received for Infant Care. Pediatrics. 2015;136(2):e315.
- Moon RY. SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2016;138(5).
- Hirsch HM, Mullins SH, Miller BK, Aitken ME. Paternal perception of infant sleep risks and safety. Inj Epidemiol. 2018;5(Suppl 1):9.