Safe Sleep Spaces & Practices
Although it may not always feel like it to parents, newborns and young infants spend a large amount of their time sleeping. Considering how much time they spend asleep, it's important to create safe sleep spaces and follow safe sleep practices to prevent or reduce adverse risks.
The purpose of this blog is to inform parents of infants about the recommended safe sleep practices and provide them with resources to use. Due to my location and area of practice, these recommendations are based on the American Academy of Pediatrics and other relevant US-based sources. Although the blog will emphasize the recommended practices, special considerations in terms of culturally relevant practices are needed. I support understanding and accommodating cultural practices, when possible, but this is better suited for a separate blog. I am not a health-care provider and the information and recommendations in this blog are not meant to replace the recommendations of your health-care provider. The recommendations and sources in this blog are, to the best of my knowledge and research, up to date at the time of writing.
“Each year in the United States, ∼3500 infants die of sleep-related infant deaths…”
What is Safe Sleep?
The American Academy of Pediatrics provides recommendations based on research and evidence that reduce the risks of Sudden Infant Death Syndrome and prevent unintentional injury or death associated with unsafe sleep (Moon, 2023). Recommendations were recently updated in 2022 and are intended for the first year of life. Safe sleep recommendations include guidance on creating a safe sleep environment and additional practices to reduce risks. Some practices, such as breastfeeding and pacifiers are recommended to reduce risk. The AAP is aware these may or may not be options families can or want to use. Below is a rundown of the Recommendations to Reduce the Risk of Sleep-Related Infant Deaths:
A Safe Sleep Environment:
Back to Sleep, for Every Sleep.
Use a firm, flat sleep surface - it shouldn't indent when your baby is lying on it. Any surface that inclines more than 10 degrees isn't safe for your baby to sleep on.
Your baby should sleep alone on their sleep surface. It is not recommended to share a sleep surface with them, and they should not share a sleep surface even as twins/multiples. Room sharing is recommended.
Avoid the use of soft objects and loose bedding. This includes pillows and pillow-like toys, quilts, comforters, mattress toppers, non-fitted sheets, blankets, toys, bumper pads, or related products that attach to crib slats or sides.
Don't use weighted blankets, sleepers, swaddles, or other weighted objects on or near your baby.
Avoid overheating
Overheating can increase the risk of SIDS. Your baby only needs one more layer than you would wear in the same environment to be comfortable.
Check your baby for signs of overheating such as sweating, a hot chest, or flushed skin.
Additional Recommendations:
Feeding of human milk is recommended, as it is associated with a reduced risk of SIDS.
Offering a pacifier at nap time and bedtime is recommended to reduce the risk of SIDS.
Never hang a pacifier around the infant's neck or attach it to infant clothing when the infant is placed for sleep or sleeping.
Avoid smoke and nicotine exposure during pregnancy and after birth. Both smoking by pregnant people and smoke in the infant’s environment after birth are major risk factors for SIDS.
This includes avoiding secondhand/thirdhand exposure and this includes vaping and electronic cigarettes, which contain nicotine.
Keep your car and home smoke-free. Do not smoke around your baby even when outside.
Avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth. There is an increased risk of SIDS with prenatal and postnatal exposure to alcohol or illicit drug use.
Routine prenatal care reduces your baby's risk of SIDS.
It is recommended that infants be immunized in accordance with guidelines from the AAP and Centers for Disease Control and Prevention (CDC).
Avoid the use of commercial devices that are inconsistent with safe sleep recommendations. Be particularly wary of devices that claim to reduce the risk of SIDS or other sleep-related deaths.
Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. Use of cardiorespiratory monitors has not been documented to decrease the incidence of SIDS.
Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods of time beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age.
There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS.
There is a high risk for death if a swaddled infant is placed in or rolls to the prone position. If infants are swaddled, always place them on the back.
Swaddling should be snug around the chest but allow for ample room at the hips and knees to avoid exacerbation of hip dysplasia.
Weighted swaddle clothing or weighted objects within swaddles are not safe and therefore not recommended.
When an infant exhibits signs of attempting to roll (which usually occurs at age 3 to 4 months but may occur earlier), swaddling is no longer appropriate because it could increase the risk of suffocation if the swaddled infant rolls to the prone position.
The recommendations are meant to reduce or prevent the risks of sleep-related deaths. Some factors and situations that contribute to these deaths are "changeable, meaning parents and caregivers can take action to lower the risk” (NIH, n.d.). Other factors may not be changeable, making it even more important to follow safe sleep practices. Below are the known risk factors:
Changeable factors include:
Sleep Position
Sleep Area/Surface
Sleep Location
Temperature
Human Milk
Immunizations
Pacifier-use during sleep
Pregnancy/Prenatal factors
Bedsharing/sharing a sleep surface
Unchangeable factors include:
Illness: Infants who have had a febrile illness, one with a high fever, within the past 2 to 3 weeks are at higher risk for SIDS.
Race/ethnicity: Some racial/ethnic groups are at higher risk for SIDS than others. Black/African American and American Indian/Alaska Native babies are at higher risk for SIDS than are White, Hispanic, and Asian/Pacific Islander babies.
Birth-related factors:
Babies born early (before 37 weeks of pregnancy) are at higher risk for SIDS.
Low birthweight babies, weighing 5 pounds, 8 ounces or less, are at higher risk for SIDS
Resources:
How to Keep Your Sleeping Baby Safe: AAP Policy Explained
Safe Sleep: Back is Best, Avoid Soft Bedding, Inclined Surfaces & Bed Sharing
Summary of Recommendations with Strength of Recommendation
Safe Sleep Guidelines That Have Been Substantially Revised Since 2016
What Are the Known Risk Factors? - Safe To Sleep - NIH
Guidelines and Safety Regulations for Sleep Products
A few organizations have created federally recognized rules and regulations, some with international recognition and varying levels of testing or requirements. The Consumer Product Safety Commission (CSPC) regulates consumer products but can’t test every product. However, the “Consumer Product Safety Improvement Act (CPSIA) gave the CPSC a significant role in creating and enforcing federal requirements as they pertain to children’s products. Testing to CPSIA means that a manufacturer meets or exceeds the federal requirement for their product.” (JMPA Cares, n.d.).
Additionally, ASTM International develops and sets voluntary standards for products around the world, focusing on performance and general requirements (JMPA Cares, n.d.). They have standards associated with multiple types of infant sleep products such as cribs, bassinets, and cradles. These are voluntary standards but good to look for.
Further certification such as the JMPA Certification Seal will ensure a product meets not only the federal and state requirements and is based on the ASTM standards, including chemical testing (JMPA Cares, n.d.). These tests include chemicals known to cause cancer, birth defects, reproductive harm, PFAS, phthalates, flame retardants, VOCs, lead, cadmium, and mercury (JMPA Cares, n.d.). For families looking for additional requirements and peace of mind, this can be a helpful certification to look for. The UL Greenguard Certifications also test for chemical emissions.
Resources:
Safety Standard for Infant Sleep Products - Federal Register
ASTM F1169-19 - Standard Consumer Safety Specification for Full-Size Baby Cribs
Safety Standard for Bassinets and Cradles - Federal Register
Inclined Sleepers, Soft Nursing Pillows, & Other Baby Products to Avoid
What a Safe Sleep Space Looks Like
A safe sleep space can be a crib, portable playpen, or bassinet that meets the current standards, is free of loose bedding and soft objects (including padded or mesh bumpers), containing only a fitted sheet (unless the manufacturer instructions suggest otherwise) using only a mattress that is approved by the manufacturer or fits their requirements, and is – most importantly – designed for infants to sleep in! Infant mattresses are much firmer than a regular mattress, even toddler mattresses can be too soft. It is important that the mattress is firm and can’t be indented.
Ideally, this will be in a shared room with a sober adult, but this is not always possible or ideal for all families.
Cords and objects should not be within reach – even if your baby is not yet mobile. Think about mobiles, curtains, cords to baby monitors, lamps, humidifiers, and toys. Dangling cords and curtains could pose a risk of strangulation. Crib bumpers, padded and mesh, pose a risk for suffocation, strangulation, and entrapment (Cleveland Clinic, 2022). Bumpers are also not necessary to prevent injury. The 2011 standard for cribs ensured all crib slats must be no more than 2-3/8 inches apart (Jana & Shu, 2023), which prevents infants from being able to fit more than their arm or leg through. Your baby may cry if they get a hand or foot stuck between the slats, but this will not cause them harm. According to the Ohio Department of Health, “There have been no cases of babies who have seriously hurt themselves by getting stuck between the crib railings. Babies aren’t capable of exerting enough force to break an arm or leg between the crib slats.”
One of the best things you can do to ensure you are using a product safely is to read the manual. This will help you ensure a product is in good condition and used correctly to prevent mistakes and misuse that could result in harm. I cannot stress enough the importance of reading these, especially when using products that may need to be adjusted or stopped based on the baby's size and development. This can be very helpful to understand when to move out of a bassinet or when to adjust the level of the mattress.
Per the AAP, a baby should only be dressed in one more layer than you would be comfortable in (for postpartum birthing parents, be aware that your own temperature will fluctuate greatly due to hormones). This is to prevent overheating, which is a SIDs risk. Check for signs of overheating as mentioned above. Each layer of fabric is considered a layer.
Always remember, even supervised unsafe sleep is still unsafe. Many sleep-related deaths are silent, you may not notice them. The best practice is to follow safe sleep recommendations for every sleep.
It is okay if a baby falls asleep in their car seat when it is properly installed into the car, but they should be removed once you’ve arrived at your destination. Your baby should not be put to sleep in the swing, if they fall asleep, move them to a safe sleep space.
Optional Sleep Supports
Swaddling has been used for a long time to soothe newborns and help them sleep. The AAP does not require swaddling for SIDs prevention or safe sleep, but they do agree that it is safe to do when done correctly (Moon R. , 2023). Remember the swaddle is a layer of clothing and many will come in different TOG ratings for measurement of warmth. Below are their recommendations:
Make sure that your baby is always on their back when swaddled.
The swaddle should not be too tight or make it hard for your baby to breathe or move their hips.
When your baby looks like they're trying to roll over, you should stop swaddling them. The risk of suffocation is higher if your baby rolls to their stomach while they're swaddled. Rolling over usually happens around 3 to 4 months, but it can happen earlier.
Some babies may experience a newborn curl that makes a newborn curl to their side, this isn’t a sign of intentional rolling but it can result in rolling, to be safe you can choose not to swaddle until their body has relaxed.
Signs of rolling:
lifting their head and shoulders more during tummy time
rolling onto their shoulders or side
kicking their legs and scooting in a circle when on their back
increased leg and hip strength, such as rolling the hips from side to side and using the legs to lift the hips up
Don't use weighted swaddle blankets or weighted objects like rice bags inside the swaddle.
Pacifiers are used to help soothe an infant and meet their sucking needs. They are associated with SIDs reduction when used correctly but are not necessary. Some babies may not like pacifiers, and they don’t need to be used for the entire duration of sleep, if it falls out don’t feel like you need to give it back.
If your baby is breastfed, wait until breastfeeding is established before offering a pacifier. That means your milk supply is good, breastfeeding is comfortable and consistent, your baby is latching well and they're gaining weight like they should. If you're not breastfeeding your baby, you can start the pacifier whenever you like.
I recommend every parent and caregiver thoroughly read the AAP recommendations for safe sleep. Recommendations change with new information, but we can do better when we know better. The recommendations aim not to scare parents or invalidate cultural infant sleep practices but to ensure that everyone is educated and aware of the risks and best practices based on research to ensure the safety of all infants. Use the information to make the best choice for your baby and family.
Additional Resources:
Safe Sleep Ambassador Training - Cribs for Kids
Back to Sleep, Tummy to Play - AAP
Inclined Sleepers, Soft Nursing Pillows, & Other Baby Products to Avoid
Safe Sleep Tips for Sleep-Deprived Parents - AAP
Putting Back-Sleeping Concerns to Rest - AAP
Sudden Infant Death Syndrome (SIDS): Common Questions & Concerns - AAP
References
Cleveland Clinic. (2022, June 13). Are Crib Bumpers Safe? Retrieved from Cleveland Clinic: https://health.clevelandclinic.org/crib-bumpers-safety
Jana, L. A., & Shu, J. (2023, May 25). Suitable Sleeping Sites: Safe at Night & Naptime. Retrieved from Healthy Children: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/suitable-sleeping-sites.aspx
JMPA Cares. (n.d.). JMPA Certified. Retrieved from JMPA Cares: https://jpmacares.org/jpma-certified
Mahoning County Public Health. (n.d.). Cribs for Kids. Retrieved from Mahoing Health: https://www.mahoninghealth.org/cribs-for-kids/
Moon, R. (2023, October 25). How to Keep Your Sleeping Baby Safe: AAP Policy Explained. Retrieved from Healthy Children: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/a-parents-guide-to-safe-sleep.aspx
Moon, R. Y., Carlin, R. F., Hand, I., & THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME AND. (2022, July). Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics, p. 150 (1): e2022057990. doi:10.1542/peds.2022-057990
NIH. (n.d.). What Are the Known Risk Factors? Retrieved from Safe to Sleep: https://safetosleep.nichd.nih.gov/about/risk-factors#:~:text=Babies%20who%20sleep%20on%20a,entrapment%2Fwedging%2C%20and%20strangulation.
