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Health Consultants For Child Care

Enhancing Health, Safety & Learning for Minnesota Child Care Providers since 1993

Is there a risk of choking when a baby is put to sleep on their back?

The American Academy Pediatrics (AAP), has found no evidence of an increase in choking or other health problems from back sleeping. Healthy babies will turn their heads to the side if they spit-up or vomit, automatically swallow or cough up fluids.  This reflex operates to make sure the airway is always open.

What about side sleeping?

Side sleeping is not recommended because it is not a stable position for babies.  Babies often roll onto their tummy increasing their risk of SUID.  The initial Back To Sleep campaign made side sleeping as an acceptable alternative to back sleeping, but “back to sleep for every sleep by every caregiver”  is the only acceptable sleep position.

What about bed-sharing?

Co-sleeping is the norm in many cultures.  In the U.S. there is much controversy about this practice.  Bed-sharing has not been found to be protective against SIDS and evidence is mounting that bed-sharing is hazardous. The AAP 2005 (reaffirmed in 2009,) recommendations describe guidelines for keeping baby’s sleep area close to, but separate from adults or other children. The AAP 2011, (reaffirmed 2016) policy statement affirms that “room sharing without bed sharing” has found to decrease SIDS by 50%.  The baby should not sleep in a bed or on a couch or armchair with adults or other children.  Infants may be brought into bed for nursing or comforting but should be returned to their own crib when the parent is ready to return to sleep.  

If parents choose to bed-share they need to realize that it is not the crib that causes “crib death”.  Bed-sharing parents need to be educated regarding the following:

  • Make sure the baby sleeps on his or her back.
  • Be aware of the risk of entrapment and strangulation – between the mattress and the framework, a wall, or other furniture.
  • Be aware of suffocation risks.  Avoid soft surfaces, pillows and loose covers.
  • Refrain from smoking or using a substance (drugs, alcohol) that may impair judgment or arousal.
  • Bed sharing may increase the risk of overheating, re-breathing, airway obstruction, and head covering. 

Many back sleeping babies have “flat” heads.  Is this harmful?

For the most part, flat spots on the back of the baby’s head are a passing condition that will disappear within several months after sleep position alters with age.  Also, as a baby’s hair grows in, these spots are less noticeable. Skull flattening can occur because newborns skulls are soft, which allows the growing brain to expand.  The medical name for this is “positional plagiocephaly”.  In extreme cases of positional plagiocephaly a helmet may be used to re-shape the baby’s head.  For the most part, these flat spots can be prevented or reduced by allowing “tummy-time” when an infant is awake and by repositioning the infant’s head while he or she sleeps.  Tummy-time promotes neck and shoulder strength and helps the baby develop the ability to roll over and crawl.  Minimizing the time a baby sits in an infant seat, or carrier to 15 minutes, which provides constant pressure to the back of the head, will also help. Infants need to be free to move for fitness. 

I see many bumper pads still sold at stores.  Are these considered to be just as dangerous as loose pillows and toys in the crib?

The AAP, U.S. Consumer Product Safety Commission (CPSC) and other health experts discourage bumper pads.  Bumpers can be a hazard for entrapment.  An infant can get caught between the bumper and mattress and wedged against the crib rail.  The bumper could pose a risk of re-breathing when an infant sleeps with his face against it.  Cribs that meet current standards should not present a hazard and bumpers should not be used.

Are there more cases of SUID/SIDS in the winter months?

The pattern of cold weather months having higher rates of SIDS deaths has decreased from 16% to 7%.  Experts are unclear about the relationship of overheating and SIDS deaths.  But, there is clear evidence that the risk of SIDS is associated with the amount of clothing or blankets on an infant and the room temperature. The goal is to keep a baby warm during sleep, but not too warm.  Babies cannot regulate their own body temperature well.  Keep a baby’s environment at a temperature that is comfortable to an adult and dress an infant with no more than 1 layer more than an adult.  Watch baby for signs of overheating like sweating and do not over bundle or cover their faces.

Doesn’t an infant sleep better on their tummy?

There is good evidence that infants sleep longer and more deeply when prone (tummy). Research suggests that this sounder sleeping may be exactly what puts a baby at greater risk of SIDS.  Babies, who are placed on their stomachs sleep more deeply, are less reactive to noise, experience less movement, and are less able to be aroused.  We need to advise parents and ourselves to accept lighter, shorter periods of sleep.  Positional preference appears to be a learned behavior among infants from birth to 4-6 months of age.  If placed on their back from day birth, most infants will become accustomed to the back sleeping position. 

If I placed an infant on their back to sleep and when I checked on them they have turned over to their tummy, do I need to flip them back to a supine (back) position? 

 Always place an infant to sleep on their back, even for naps.  The AAP recommendations for parents at home outlines once a child can turn over on their own, something that typically happens around 4 to 5 months of age, there is no need to keep turning them back to a supine position.  Although the infant’s risk of SIDS could be increased slightly if he or she spontaneously assumes the tummy position, the risk is not sufficient to outweigh the great disruption for the caregiver or the infant to keep checking sleep position.  When infants unexpectedly fall asleep on their tummy (i.e. during awake tummy-time) they should be gently turned onto their backs and placed in their crib.2    The 2013 MN DHS regulations add a protective measure outlining guidelines that differ from this practice.  

What are the AAP 2005 (Reaffirmed 09, 11, 16) guidelines regarding the use of pacifiers?

 Several studies report a protective relationship between pacifier uses and reducing SIDS.The reason for this relationship is unclear but possible explanations include:  

  1. Sucking enhances alertness keeping infants from a deep sleep.
  2. Pacifiers enhance babies swallowing.
  3. The pacifier serves as a mechanical barrier between the mouth and any potential for blocked airways.
  4. The presence of a pacifier in the mouth may discourage babies from turning over onto their faces during sleep.

The AAP offers these guidelines for pacifier use: 

  • Advises delaying pacifier use for breast-fed infants during the first month of life to ensure that breast-feeding is firmly established.
  • Offer a clean, dry pacifier at naptime and bedtime but don’t force the baby to take it.
  • If the pacifier falls out after the baby falls asleep it does not need to be reinserted.
  • Discontinue use of a pacifier after age one.

Important Reminder – Never hang a pacifier around a child’s neck. “Pacifier keepers” or stuffed toys that attach to a pacifier are not recommended but should always be removed when putting a child to sleep.  MN 2013 DHS regulations allow pacifiers as the only item in a crib; one-piece blanket sleepers are allowed.

References: First Candle/SIDS Alliance, AAP Talk Force on infant Sleep Position and SIDS, Child Health Alert, NSIDPSC.