Does your baby snooze in a SIDS safe sleep position?

As the name suggests, ‘sudden infant death syndrome’, or SIDS, is the sudden or unexplained death of an infant less than or up to 12 months of age.¹ In the US, there are at least 1000 annual deaths due to SIDS.² Cases of SIDS, previously known as ‘cot death’, have declined since the ’90s with the introduction of safe sleep recommendations – a key point being to place infants on their backs (supine position).³ Since paediatricians started to recommend supine sleeping, the number of babies who have died from SIDS has plummeted by 80% worldwide.⁸

Muffled Messages

If you haven’t heard about this, you’re not the only one. A fifth of US mothers are still putting their infants in a non-supine position (on their side, on their stomach) within six months of birth.³ This tracks with 2022 statistics which showed that 90% of SIDS cases occur within an infant’s first six months.³

So, let’s talk about safe sleeping. What is it and how can you incorporate it into your bedtime routine?

The Triple Risk Model

We don’t know what causes SIDS, but researchers have developed a framework for understanding how it may occur. It’s called the ‘triple risk model’.^1,4

This model proposes that SIDS happens when an infant with an intrinsic vulnerability is exposed to an external trigger during a period of critical development.¹

Intrinsic vulnerability – any underlying biological issue that can affect the baby’s heart rate or breathing. This could be due to genetics, unseen injury at birth, or a viral infection⁹.
External triggers – this includes an unsafe sleeping environment or position.
Critical development period – the first six months of an infant’s life is a time of fast change which can leave them vulnerable to external triggers.

Safe-Sleep Recommendations

To help avoid SIDS, the American Academy of Pediatrics (AAP) recommends certain practices.

These include^1,5:

Putting the baby to sleep on their backs
Using a firm, non-inclined sleep surface
Room sharing without bed sharing
Avoiding soft bedding like quilts, non-fitted sheets
Avoiding overheating the infant
Avoiding commercial ‘wellness’ devices that are not compatible with safe sleep recommendations
Placing the infant on their back, especially if swaddled. There is a high risk of death if a swaddled baby is put in or rolls into the prone (face down) position.

WARNING!
Wellness devices are increasingly being touted as a way to avoid SIDS. These can include cardiorespiratory monitors that claim to track the infant’s vital signs as they sleep. Many parents use them as it brings some peace of mind but there is no proof that they help to lower the risk of SIDS.

NOTE BENE: Governments do not require ‘wellness devices’ to meet the same standards as ‘medical devices’.

Additional recommendations include:

Following guidelines for the frequency of prenatal visits
Breastfeeding, if possible
Avoiding exposure to alcohol, nicotine, marijuana, opioids during pregnancy and after birth
Getting your baby vaccinated on time
Using pacifiers (if breastfeeding is already an established part of your baby’s routine).
Avoiding home cardiorespiratory monitors as a strategy to reduce the risk of SIDS (see callout box)
Including supervised, awake tummy time to encourage infant development

Why You Should Try Supine

Paediatricians recommend the supine sleeping position because it’s the best position to keep the baby’s airways unobstructed and protected from both reflexive swallowing or choking on regurgitated milk.⁶

Not only is the ‘Back to Sleep’ campaign the official policy of the AAP, but it is also supported by international data from at least 13 countries that have likewise implemented supine sleeping campaigns.⁷

What’s Wrong With Side Sleeping?

If you’re a side sleeper yourself, you may be wondering what the big deal is. Why do doctors recommend against it for babies?

For infants (up to 12 months), the side sleep position can ‘increase the risk of rebreathing expired gases’ which can lead to too much carbon dioxide and too little oxygen in the blood.¹

Side sleeping also increases the risk of overheating and can impact the efficiency of the baby’s heart.¹ This can mean that enough oxygen isn’t reaching the baby’s brain.¹

The side sleep position is also inherently unstable and can often lead to the baby rolling over onto their stomach – another high-risk sleep position.¹ Reduce your baby’s risk of SIDS with safe sleep positions.

High-risk Front Sleeping

Prone, or face down, sleeping is the highest-risk sleeping position. Very young babies cannot flip themselves onto their back or side if they start to find it difficult to breathe.

Some experts have found evidence that oxygen saturation drops when an infant is left to sleep on their stomach.⁸ Some doctors believe that this, combined with a respiratory infection, can make it very tough for a baby to get enough oxygen, leading to a high risk of SIDS.⁹ Safe sleep positions are demonstrably important to keep the risk of SIDS low.

Since physicians started sharing the risks of prone sleeping, the number of SIDS deaths has dropped dramatically. Whether this is because the position keeps a baby’s nose and mouth clear, makes it easier for their ribs to expand, or even lowers the risk of picking up a respiratory infection from bedding, the result is the same-better breathing.

What’s keeping you from changing position?

So, what’s stopping you from sticking to the supine sleeping position? When asked, parents have reported that they were concerned about laying the baby on its back.¹

They worry that:

The baby is uncomfortable sleeping on its back

An infant waking up frequently is an expected and normal part of their physiologic response at that age. The data does not suggest that sleep quality decreases in the supine position.

The baby will aspirate or choke

Coughing or gagging is a normal protective reflex and is not the same as choking. Paediatricians have carefully and thoroughly investigated this issue. None of the published data reported an increased risk of airway blockage with supine sleeping.

Looking to Learn More about SIDS Safe Sleep positions?

If you want to see all of the recommendations in more detail, you can view the AAP’s most recent policy statement here.

References

1. Moon RY, Carlin RF, Hand I, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME and THE COMMITTEE ON FETUS AND NEWBORN. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991. doi:10.1542/peds.2022-057991

2. What is SIDS? | Safe to Sleep®. Accessed December 30, 2024. https://safetosleep.nichd.nih.gov/about/sids-definition

3. Ding G, Peng A, Chen Y, Vinturache A, Zhang Y. Nonsupine Sleep Position Among US Infants. JAMA Network Open. 2024;7(12):e2450277. doi:10.1001/jamanetworkopen.2024.50277

4. What Causes SIDS? | Safe to Sleep®. Accessed December 30, 2024. https://safetosleep.nichd.nih.gov/about/causes

5. Moon RY, Carlin RF, Hand I, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND THE COMMITTEE ON FETUS AND NEWBORN. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990

6. Supine_Is_Safest_A1Poster.pdf. Accessed January 2, 2025. https://rednose.org.au/downloads/Supine_Is_Safest_A1Poster.pdf

7. Bergman NJ. Proposal for mechanisms of protection of supine sleep against sudden infant death syndrome: an integrated mechanism review. Pediatr Res. 2015;77(1):10–19. doi:10.1038/pr.2014.140

8. Shepherd KL, Yiallourou SR, Horne RSC, Wong FY. Prone sleeping position in infancy: Implications for cardiovascular and cerebrovascular function. Sleep Medicine Reviews. 2018;39:174-186. doi:10.1016/j.smrv.2017.10.001

9. Goldwater PN. SIDS, prone sleep position and infection: An overlooked epidemiological link in current SIDS research? Key evidence for the ‘Infection Hypothesis.’ Medical Hypotheses. 2020;144:110114. doi:10.1016/j.mehy.2020.110114