Module 8: Safe Sleep
Safe sleep is an important topic in newborn care, though it’s one that’s associated with a lot of cultural variance. In this module, we’ll review the most important things to keep in mind about safe crib environments and co-sleeping.
Why Are We Trying To Prevent With Safe Sleep Practices?
Our goal is to minimize Sudden Infant Death Syndrome (SIDS), which is when an infant dies suddenly during sleep. We don’t exactly know the cause of this. Sometimes, it’s due to a combination of immature respiratory centers with unsafe sleep environments. Other times, it could occur due to an abnormal heart rhythm, seizure, or genetic disorder. Not knowing the exact cause is scary. However, there’s things we can do to help!
Some risk factors for SIDS are outside of your control, such as prematurity, age (<4 months), and low birth weight. Some, though, can be modified so that SIDS is less likely to occur. These include breast/chest-feeding, avoidance of smoking (especially during pregnancy), using a pacifier, getting routine infant vaccinations, and creating a safe sleep environment.
We also aim to prevent accidental suffocation, strangulation, and wedging (when an infant gets stuck, such as between a wall and a pillow, and is unable to breathe).
Where Should My Baby Sleep?
The current recommendation by the American Academy of Pediatrics (AAP) is room-sharing (but not bed-sharing) for at least the first 6 months of life. This means having a crib or bassinet in the same room as your bed, though not co-sleeping. There’s evidence that room-sharing can decrease risk of SIDS, and it’s also reassuring and helpful to have easy access to your newborn overnight for feeds or if they’re distressed and need help. With co-sleeping, there’s higher risk of SIDS and suffocation, which is why they AAP recommends to exclusively room-share instead.
Note: As a Pediatrician, I counsel to avoid co-sleeping. However, I also recognize that there’s a lot of judgement around this topic, to the extent that families feel so shamed that they avoid discussing it with their PCP altogether, anticipating a lecture. It’s important to realize that co-sleeping is more of the norm globally and that there’s a large cultural component influencing a family’s choice, especially within immigrant households. It’s also essential to recognize that there are many families that do co-sleep within the U.S, and ignoring this fact doesn’t help us support them doing it in the safest way they can. If you choose to co-sleep, see the end of this module for how to lower SIDS and suffocation risk as much as possible.
What Should My Baby’s Crib Look Like?
Location & Setting:
Try to set up your crib around 2-3 feet away from a window, if able. There’s a few reasons for this. One is that near windows, temperature isn’t the most stable. If it’s a hot and sunny day, your newborn may get too warm, or risk UV exposure leading to sunburns. In a similar vein, on a cold day near a window with inadequate insulation or a draft, they can get too cold too quickly. Another reason is that window curtains and blinds often have cords, which can be a strangulation risk. Windows can also shatter, serve as an entry for insects, and can get accidentally opened, which is dangerous once your infant gets older and is able to stand.
You can hang a mobile above the crib, just make sure it’s at a high enough height and doesn’t have any dangling strings or ribbons that can act as a strangulation risk.
If there’s any shelving or artwork near the crib, make sure it’s anchored to the wall firmly (this goes for any nearby furniture, as well). If you live in earthquake territory, like I do in California, you may consider hanging stuff on a different section of the wall to avoid the higher risk of something falling into the crib. Another option is to leave a small gap between the crib and the wall, so that if artwork falls, it goes onto the ground, rather than into the crib.
Crib Interior:
Keep it sparse! You’ll want the crib to meet CSPC (Consumer Product Safety Commission) Guidelines and have a firm, flat mattress designed to fit your crib. You want it to be snug against the edges, without any gaps where wedging can occur. Avoid installing it on an incline to ensure the airway stays clear (in recent years, some doctors recommended a slight incline to help reflux, though this is no longer recommended). On top of the mattress, you’ll want a fitted sheet. And that’s it!
Note: If you’re interested in making sure your crib hasn’t been recalled by the CSPC, click here.
While pillows, blankets, and stuffed animals are cute for decoration and are fine to keep in the crib when your newborn isn’t inside of it, they should get completely cleared for naps and overnight sleep to decrease suffocation risk.
Avoid crib bumpers. They add soft surfaces that can increase changes of suffocating.
How Should They Be Positioned?
On their back! There’s been a large Back To Sleep campaign in recent years, and it’s because there’s a marked decrease in SIDS when babies fall asleep in this position. In the first few months, if for some reason you find them on their stomach while checking in, always reposition them to their back. Once your infant reaches 4-6 months (which is when they should start rolling over), you don’t necessarily need to reposition them if you realize they’ve shifted. If they can consistently turn from front-to-back and back-to-front, then it’s OK to leave them as they are.
A Note On Co-Sleeping
As mentioned above, there’s a lot of shaming around co-sleeping. While I advise room-sharing instead, I know there’s a lot of factors (especially cultural) that influence a family’s decision, and my goal is to ensure that whatever choice a family makes, they’re executing it as safely as they can.
Suffocation, strangulation, and SIDS are highest in the first 4 months of life and in premature / very low birth weight infants. If able to avoid co-sleeping in these higher-risk situations, that’s optimal. If choosing to co-sleep with a healthy infant in the first 4 months, here’s what to consider:
Avoid sofas, which have much less firmness and more risk of wedging. Always use a bed.
Have a firm mattress. Minimize comforters and pillows as much as you can. Clear the bed of toys, clothes, or any other extra items that may have accumulated. Make sure there’s no gaps between the mattress and the headboard where wedging can occur.
Use the side-sleeping / “C” position. You’ll be lying on your side, curled up with your legs tucked under your infant’s feet (similar to the side-lying position for breast/chest-feeding), and your infant will be on their back.
Keep other children and pets out of the bed if you’re co-sleeping with an infant.
Avoid alcohol and smoking, or any other situations (like medications that cause drowsiness) where you’ll feel too tired or disoriented to care for your child as well as your would if alert.
What If My Infant Falls Asleep Somewhere Other Than A Crib?
While it always stinks waking up a sleeping infant, since it can take a while to get to that peaceful slumber, it’s more important to make sure that they’re sleeping in a safe environment. If your newborn falls asleep in a carseat, Dock-A-Tot, or Boppy, move them to their crib. These other devices aren’t rated for infant sleep and there’s been instances of sad outcomes if left there.
There are some other surfaces (like travel bassinets, baby tents, beside sleepers, and play yards) that can be considered safe if they are in compliance with the recent CPSC Guidelines.
