Safe Infant Sleep

Parents and caregivers, such as child care providers and babysitters, should place infants on their backs during every sleep period until one year of age. Sleep positions that leave babies on their stomachs or sides have the potential to increase the risk of SIDS. The problem with the side-sleeping positions is that babies can easily roll onto their stomachs.

Some parents worry that infants will choke if they spit up while they’re on their backs. But babies have a natural gag reflex to help keep their airways clear, which causes them to automatically cough up and swallow fluids. Even babies with gastroesophageal reflux disease should sleep flat on their backs.

As babies grow, they might roll onto their stomachs. If your baby rolls back and forth comfortably, then you don’t need to keep turning them onto their back.

When traveling, plan a safe sleep environment ahead of time, such as by bringing a portable crib that complies with American Academy of Pediatrics recommendations.

Use a crib, bassinet or other approved sleeping space that has a firm, flat surface. For cribs, make sure the mattress is firm and only use a fitted sheet. Nearly 40% of U.S. infant deaths are attributed to soft bedding.

If your baby falls asleep in a car seat or swing, move them to a firm, flat sleep surface and place them on their back.

Bed sharing is when an infant sleeps with another person, such as a sibling or a parent, on a bed. Bed sharing also includes other sleep spots, such as on a couch or recliner. When a baby shares a sleep space with someone, it increases the risk of SIDS, suffocation and other infant-related deaths. No matter how convenient it is to bed share with your baby, even if you’re sleep-deprived or traveling, it’s best not to. A baby’s risk of suffocation increases due to pillows, blankets or other loose or soft bedding; individuals rolling over on them; or their becoming trapped between the headboard, mattress, bedframe, wall or other furniture.

If you want your baby to sleep nearby, it’s better to place an American Academy of Pediatrics-approved separate crib, portable crib or bassinet in your room than bringing your baby into your bed.

Room sharing is recommended for the first six months of your baby’s life, per the American Academy of Pediatrics, because it can decrease the risk of SIDS by as much as 50%, and makes it easier for you to feed your baby — especially newborns — throughout the night. But keep your baby in a separate bed just for them.

All infant sleep areas should be completely clear of anything but a fitted sheet. Stuffed animals and bed decorations may look cute, but they can increase the risk of suffocation and strangulation. Even though most crib bedding sets are sold with accessories such as bumper pads and pillows, an empty crib is the safest space for your baby to sleep.

Take it one step further by making sure there are no small objects that have strings or wires within your baby’s reach. Those objects can increase your baby’s risk of strangulation.

Overheating can increase the risk of SIDS. Babies only need one more layer than you would wear in the same environment. If you swaddle your baby, the material should not be wrapped higher than the baby’s shoulders. Swaddling should be discontinued when your baby is able to roll over.

When your baby is placed to sleep, make sure their head and face are uncovered. Signs of babies overheating could be flushed skin/cheeks, sweating or a hot chest.

The New Parent Support Program provides education and support for expectant parents or those with children through 3 years of age. Services are voluntary and often delivered via home visits. The program offers a variety of services, including providing information about prenatal health, infant care, nursing/breastfeeding, early child development, bonding with your baby, safe sleep environments, parenting education and more.

The New MilParent specialty consultation from Military OneSource provides support for expectant parents and parents of children through 5 years of age on a variety of parenting topics, from developing a routine to solving sleep issues for yourself or your child. Those seeking support from this program may include parents:

• Seeking help with parenting concerns
• Separated from family support
• Experiencing a spouse’s deployment
• Who are single and parents facing the challenges of serving in the military

Sleep-related infant death is defined as a sudden, unexpected infant death that occurs during an observed or unobserved sleep period, or in a sleep environment.

Sudden unexpected infant death is a death that, whether explained or unexplained, occurs during infancy. SUID includes SIDS and accidental suffocation and strangulation in bed. SUID also includes multiple possible causes of infant death, such as:

• Infection: When an infant has an infection caused by a virus or bacteria that makes breathing difficult
• Ingestion: When an infant has something in their mouth that blocks their airway and causes choking
• Metabolic diseases: Disorders related to body functioning that can lead to breathing problems
• Cardiac arrhythmias: When an infant’s heart beats too fast or too slow and affects breathing
• Trauma: Physical injury, whether intentional or unintentional

In some cases, the evidence is not clear or not enough information is available, so the death is considered to be of unknown cause.

SIDS is defined as a cause of infant death that cannot be explained even after a thorough investigation, including a death scene investigation, autopsy and review of the clinical history. It is only one of the potential causes for sleep-related deaths and falls under the SUID umbrella.

The triple-risk theory provides a widely accepted understanding of how three main elements may influence and lead to SIDS.

• The first element is an undetected vulnerability in the infant. This may include a brain abnormality, such as an arousal deficit or a genetic mutation that may cause a respiratory or cardiac defect. Research in detecting these abnormalities continues to advance. For example, a newly released study identified a deficit in the enzyme biomarker Butyrylcholinesterase as possibly being linked to SIDS deaths.¹
• The second element is related to the fact that all infants undergo a critical developmental period in the first six months that affects their ability to regulate physiologic systems within their body. This is a period of rapid growth and development, and at times an infant’s physiologic systems may temporarily destabilize. For example, an infant may have a sudden change in respiratory rate, blood pressure, body temperature or sleep arousal. Additionally, an infant’s anatomy places them at greater risk for a compromised airway (i.e., large head, short neck and weak neck muscles).
• The third element refers to an infant’s ability to manage external/outside stressors within their environment. Environmental factors, such as having an infant sleep on their stomach, co-sleeping, exposure to secondhand smoke or overheating during sleep, place them at increased risk. If the infant is already vulnerable due to the other two elements, they are more likely to have difficulty adapting to the outside stressors, and their risk of death increases.

According to the triple-risk theory, all three elements must be present for SIDS to occur. SIDS can be reduced if caregivers remove the outside stressors by following the 2022 AAP recommendations for reducing infant death in the sleep environment.

¹Harrington, C.T.; Hafid, N.A.; and Waters, K.A., (2022). Butyrylcholinesterase is a potential biomarker for sudden infant death syndrome. eBioMedicine, 80(104041). https://doi.org/10.1016/j.ebiom.2022.104041

Accidental suffocation or strangulation in bed is a cause-of-death code used for vital statistics purposes. This code is used to identify infant deaths caused by suffocation (when no air reaches a baby’s lungs, usually because of a block in the airway); overlay (when another person shares a sleep surface with the infant and lays on or rolls on top of or against the infant while sleeping, blocking the infant’s airway); entrapment (when an infant becomes trapped between two objects (such as a mattress, wall, bedframe or furniture); or strangulation (when something presses on or wraps around the infant’s head and neck, blocking the airway). ASSB is a common cause of infant sleep-related death and is an outcome that is 100% preventable.