Knowing about safe sleeping positions for babies is important in ensuring a safe sleep environment and preventing the risk of sudden infant death syndrome (SIDS). SIDS falls under the category of sudden unexpected death in infancy (SUDI) and is majorly linked to the position in which the baby sleeps. Thus, knowing what positions are safe for your baby to sleep in is important to help prevent unexpected situations. Also, knowing a few tips that will help reduce the risk of SIDS helps go a long way (1). One example of such a position of safe sleeping in babies is the supine position, in which the baby, who is less than a year old, is made to sleep on their back. Read on to know more about safe sleeping positions for babies and tips on sleep safety.
The Good And Bad Positions For A Baby To Sleep
It is essential to learn about the safe and unsafe sleeping positions for a baby to deal with the above risks (2).
1. Sleep on back
Healthy babies born full-term should be placed on their backs for naps, short periods of rest, and sleep at night.
- ‘Sleep on the back’ position was found to lessen the risk of SIDS in babies, as it keeps airways open.
- The US National Institute of Child Health and Human Development (NICHD) labeled this as the best sleeping position for babies (3).
- Since the American Academy of Pediatrics made the ‘back-to-sleep’ recommendation in 1992, the SIDS rate has dropped more than 50%. The ‘back-to-sleep’ recommendation was later campaigned as ‘safe to sleep’ (4).
Risks Involved In ‘Sleep On Back’ Position
If infants are placed on the back for a long time, it may lead to ‘positional plagiocephaly,’ a case of flattened or misshapen head and ‘brachycephaly,’ the flattening of the back of the skull. The shape will become normal by the time they turn one year and rarely requires any treatment Simple repositioning techniques may be employed to avoid such conditions. They include:
- Increasing ‘tummy time’ of the baby when awake
- Making the baby rest on the other side of the head rather than the flat side.
- Cutting down the time spent by babies in carriers or car-seats.
- Getting more ‘cuddle time’.
- Changing the direction of the baby in the crib so that they do not always view the same things, and in one direction always.
2. Sleep on stomach
Several theories discourage parents from making a baby sleep on the stomach because:
- It could put pressure on a baby’s jaw, reducing the airway and restricting breath.
- If the baby sleeps on the stomach, i.e., in the prone position, they may be lying with the face very close to the sheets and breathing the same air.
- The baby may suffocate while sleeping on the stomach if the mattress is very soft.
- The baby may also breathe in microbes present on the mattress.
When Can Babies Sleep On Stomach?
In rare cases, due to a medical condition, doctors may advise parents to make the baby sleep on the stomach rather than the back.
- A few physicians believe that sleeping on the stomach could be good for babies with severe gastroesophageal reflux or certain upper-airway malformations like Pierre Robin Syndrome, which lead to acute airway obstruction episodes. However, no recent study supported or refuted the benefits. Healthcare providers should consider the potential benefits and risks before recommending this position.
- The danger of vomiting was the most important argument for making the baby sleep on its stomach. This is because doctors believed that it would be dangerous if the baby vomits while sleeping on the back. They argued that babies might choke on their vomit, due to lack of enough strength to turn the head. However, babies sleeping on their backs may not have as much difficulty turning their heads and vomiting the contents of the stomach out.
- Also, you may make a baby with colic sleep on the stomach to relieve them of gas. However, do not do it immediately after feeding them. Let there be some gap between the feed and the sleep time.
3. Sleep on the side
It is unsafe for babies to sleep on the side because they may end up on the tummy, increasing the risk of SIDS.
In addition to the good and bad sleeping positions, you must also know about the sleeping practices that could lead to a sudden unexpected death in infants.
Sleeping Practices That Could Lead To Sudden Unexpected Death In Infancy (SUDI)
SUDI includes both SIDS and other fatal sleeping accidents. Here are a few practices that could lead to SUDI:
- Making the baby sleep on the stomach or side.
- Putting the baby to sleep on soft surfaces such as mattress, sofa, waterbed, pillow, or lamb’s wool, either with or without a parent around.
- Covering the baby’s head or face with bedding, which may cause accidental suffocation and overheat.
- Smoking during pregnancy or after childbirth.
SIDS can be a significant risk and should be considered when you follow certain steps to ensure that your baby sleeps safely.
11 Tips For Safe Baby Sleep
For babies who are healthy and under one year of age, sleeping on the back is the ideal position. However, some extra measures would be helpful to ensure safe sleep for your baby (1).
- Avoid loose bedding: It is advisable to use a firm mattress rather than an overly soft mattress, waterbed, or sofa for your baby. Experts suggest against the usage of bumper pads, pillows, fluffy bedding or stuffed animals around the baby in the crib. In simple words, anything that could cover a baby’s head or face during sleep is not recommended.
- Keep the crib simple: Do not use wedges, quilts, or comforters under an infant in the crib. Let the infant sleep with the feet touching the bottom of the crib so that he can’t wriggle down under the bedding. Use a firm, clean mattress that fits the cot well and tuck in the bedclothes securely. The sides or ends of the crib should be high enough to prevent the baby from climbing out or crawling out.
- Avoid covering the baby’s head: Blankets should be covered only up to the chest of the baby with arms exposed, to avoid the shifting of the blanket onto the head and thereby preventing suffocation. The American Academy of Pediatrics recommends using ‘sleep sack’ or ‘baby sleep bag’ as a type of bedding to keep him warm without covering the head. Sleeping bags with a fitted neck and armholes and no hood are considered the safest. Wrapping a baby in lightweight cotton or muslin also helps in preventing him from rolling onto the tummy during sleep.
- Avoid overheating: Infants should be clothed lightly for sleep. Avoid over-bundling and check if the baby is not hot to touch.
- Good sleep environment: It is important to maintain a considerably cool sleeping environment with a temperature of around 20oC for the baby.
- Vaccination: An investigation done on diphtheria-tetanus-pertussis immunization and potential SIDS association by the Berlin School of Public Health has concluded that increased DTP immunization coverage is associated with decreased SIDS mortality (5). Current recommendations on timely DTP immunization should be emphasized and followed to prevent not only specific infectious diseases but also potentially SIDS.
- Use a pacifier (at sleep times): The American Academy of Pediatrics considers pacifiers could prevent SIDS. However, do not force the baby if they do not want it or if it falls out of the mouth. If you are breastfeeding, wait until it is well established before beginning to use a pacifier. It usually takes around three to four weeks of age for the baby to get comfortable with breastfeeding.
- Use technology: If you are worried about the baby’s sleeping position, especially when they are in a separate room, use Wi-Fi baby monitors, app-powered thermostats, or small alarms to monitor the sleep position as well as vitals of your baby.
- Avoid use of products that claim to prevent or reduce SIDS. This is crucial as scientifically, there is no known way to prevent SIDS. Safety and efficacy of wedges, positioners, or other such products that claim to prevent SIDS are not proven. On the contrary, various incidents have been reported where these products have been associated with injury and death when used in the baby’s sleep area (6).
- Share the same room: You may share the same room with the baby for convenient breastfeeding and contact. The crib in which the baby sleeps should be closer to parents.
- Avoid sharing the bed: Experts suggest that infants ideally should not share the bed with parents, adults, siblings, or other children. Twins or multiples may be made to sleep separately. Do not share a bed with your baby, especially if you or your partner have been drinking, smoking, or taking medications or drugs that could induce deep sleep. Smoking and the use of a substance like drugs or alcohol significantly increase the risk of SIDS and suffocation in babies, if the bed is shared.
Frequently Asked Questions
1. What if the baby rolls onto the stomach while sleeping?
Around four to five months of age, babies begin to roll over onto their stomach from their back (7). This can be alright as the SIDS risk generally lowers by this time. Let the baby find a comfortable sleeping position; they may be able to turn the face to the side to keep the mouth and nose free for breathing when sleeping on the stomach. In any case, always place the baby on the back when you put them down on the bed to sleep.
Note that the SIDS risk is at a peak between one and four months of age, but it remains a threat until babies are 12 months old. So, follow other precautions to reduce the risk of SIDS all through your baby’s first year.
2. Why does my baby sleep in fencing reflex while in the back-to-sleep position?
Babies exhibit many involuntary movements as they grow. One such move is the Fencing Reflex or Tonic Neck Reflex (8). When placed on the back-to-sleep position, the baby’s head turns to one side with the arm and leg of that side extended, while the other arm and leg are flexed. This is called the fencing position, which helps prevent a baby from rolling over onto the stomach before the body is ready for it. This is one more reason for putting your baby to sleep on the back. This involuntary movement will disappear anytime between three to six months of age.
3. When can the baby be on its stomach?
The baby may be put on the stomach, but under supervision, when awake. Giving tummy time for babies is a good way to strengthen their stomach, back, and neck muscles.
According to Dr. Karen Sokal-Gutierrez, clinical professor, community health and human development, University of California Berkeley-UCSF Joint Medical Program, SIDS risk is lowered with babies spending more tummy time when they are awake (9). Moreover, the baby would develop upper body strength needed to lift the head and roll over in sleep.
4. Can I use infant sleep positioners for my baby?
There is no US FDA approval for infant sleep positioners to reduce or prevent the risk of SIDS in babies.
5. What if babies throw up when sleeping on the back?
There is a low risk for healthy babies to choke on vomit when made to sleep on their backs than on their sides or tummies. Sleeping on the back does not increase choking risk in babies with gastroesophageal reflux disease either. But do not put the baby to bed with a bottle propped for feeding. This practice could lead to ear infections and choking.
6. What to do if my baby has difficulty sleeping on the back?
A few infants may not have a deep sleep in the back-to-sleep position. Some may even become fussy when placed on the back.
The baby may not feel comfortable sleeping on the back if they have a congested nose. In such a case, place a humidifier in the baby’s room to moisten the air and loosen the congestion. Elevating the head slightly could minimize the discomfort from a stuffy nose.
7. What if my baby throws up while sleeping?
If your baby throws up, turn their head to the side. Clean up the vomit and change the bedding before you put the baby back to sleep again.
8. What are the best sleeping positions for preterm babies?
According to a research study, preterm infants are at a higher SIDS risk, and they are to be placed on the back-to-sleep position (10). However, in a highly monitored inpatient setting, sleep on stomach position may be appropriate in case of acute respiratory disease in preterm infants.
In the first few months, you need to be extra careful with your baby and their habits, including their sleeping position. Learning about the right sleeping position for babies holds great importance in ensuring their safety and preventing any unfortunate events such as SIDS. What may seem like a normal harmless position, such as sleeping on the side and the stomach or sleeping on too soft surfaces, can increase the risk of the condition. So consult your doctor to know about safe positions for your baby to sleep in and follow the precautionary tips to help your baby have a safe and comfortable sleep.
2. Infant Sleep Position And SIDS; National Institute of Child Health And Human Development
3. Healthy Native Babies; National Institute of Child Health And Human Development
4. Safe to Sleep; National Institute of Child Health And Human Development
5. Müller-Nordhorn J et al.; Association between sudden infant death syndrome and diphtheria-tetanus-pertussis immunisation: an ecological study.; National Center For Biotechnology Information (2015)
6. Baby Products with SIDS Prevention Claims; US FDA
7. Important Milestones: Your Baby By Four Months; Centers For Disease Control And Prevention
8. Newborn Reflexes; Stanford Children’s Health
9. Preventive Health and Safety in the Child Care Setting; California Childcare Health Program
10. J M D Thompson and E A Mitchell; Are the risk factors for SIDS different for preterm and term infants?; National Center For Biotechnology Information (2006)