There are no warning signs for sudden infant death syndrome (SIDS) or sudden unexpected infant death (SUID). But research shows a relationship between these two conditions and safe sleep. In fact, in the 1990s, the U.S. saw the biggest drop in SIDS — over a 50% reduction — from its Back to Sleep campaign, proving the importance of creating a safe sleep environment for infants.
Still, there are a dizzying number of sleep-related products on the market for infants, and even more opinions on what safe sleep really means. Children’s Hospital Colorado neonatologist Susan Hwang, MD, MPH, PhD answers some of the most pressing sleep-related questions on parents’ minds and offers her expert advice below.
How are sleep and SIDS/SUID related?
We have studies that show that hypoxia, or low oxygen levels, is on the pathway toward the eventual tragic experience of SIDS or SUID. These infants have a period when they are not breathing effectively and their oxygen levels are low, and that is associated with the cascade of issues that lead to SIDS or SUID.
Now at a population level, we know that when state child fatality review boards investigate SIDS or SUID deaths, they almost always identify at least one unsafe sleep practice around the time of infant death.
What do the guidelines tell us about a safe sleep environment?
The latest American Academy of Pediatrics (AAP) guidelines were published in 2022. And at the core, many of the updates are the same as those published in 2016, including that infants should have a separate sleep space apart from the adult caregiver’s sleeping area. Babies should also be totally flat on their backs, lying on a firm mattress with nothing else in the crib that they could potentially suffocate on. So, there’s no crib bumpers, no blankets and no pillows. Most babies can sleep in a sleep sack or a swaddle; however, those that can roll over should not be in a swaddle.
The AAP guidelines also note that positioning devices should not be used for sleep. And in fact, since the publication, some of these devices have been banned by our U.S. Consumer Protection Safety Commission, including the Rock n’ Play. Weighted blankets also are very problematic and have been banned for use during infant sleep.
How else can parents and caregivers prevent SIDS?
There are a few things to consider:
- Temperature control
- Breastfeeding as a protective factor
- Reducing secondhand smoke exposure
- Substance use (alcohol, marijuana, etc.) that could cause fatigue in caregivers
The general health of the infant is important, too. We know that routine vaccinations and having doctors involved in the infant’s care regularly is important.
The other thing that is worth mentioning, especially with the winter season coming on, is that infants who’ve had a recent cold — especially those that have needed to be hospitalized and are still recovering — are at higher risk for SIDS and SUID. Safe sleep is always very important, but especially for infants who’ve been hospitalized.
What are some of the barriers to creating a safe sleep environment that parents and caregivers might face?
After the first month of life, SIDS and SUID is the leading cause of infant death in the U.S. Social determinants of health (economic status, race, ethnicity, etc.) influence both the health of the infant and the family’s ability to practice behaviors that reduce or increase risk.
To have good safe sleep practices, we need a separate sleep space that is well-ventilated, the temperature has to be within a certain range and there’s enhanced breastfeeding. If we think about the families that can or cannot do that, you can sort of begin to understand how social determinants can impact safe sleep practices. What is the home arrangement? Maybe it’s all the family members in one room, maybe the baby can’t have a separate sleep space. If it’s temperature control, and they’re in public housing, they have no control over the thermometer. We know that breastfeeding is protective, but many mothers don’t have paid leave and are returning to work. And so, you can see how these things influence a family’s ability to practice safe sleep.
How can we start to overcome these barriers?
Ideally when patients are getting prenatal care, they have referrals in place to agencies that can be screen and provide resources. And then when they are hospitalized to give birth, our team should be screening for these social determinants of health to connect families with the resources they need.
Organizations like Cribs for Kids provide Pack n’ Plays to create a separate sleep space. And if worse worsens, you can still adhere to the core principles of safe sleep. For example, even a drawer pulled out of a dresser can work, right? It is a separate sleep space that’s totally flat. The other example I’ll give is baby boxes. Baby boxes were popular a few years ago, and some state agencies were delivering them to all new families. We found some issues with the baby box, but I always say that if the baby box is the only option aside from co-sleeping, then use it. Both of these options create a separate sleep space where the infant can be placed flat on their back on a firm surface, without any other unsafe objects in the sleep area.
We think about the cliché, “It takes a village to raise a child.” And if you think about other developed countries and why they have lower infant mortality rates, they have a very developed social safety net system that supports families with generous maternity leave and really robust childcare benefits. It’s not just one family totally on their own trying to make ends meet to raise this new baby, but truly there is a system that envelops these families and allows them to do what’s considered safe for their baby.
Learn more about safe sleep practices.
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Author: Mile High Mamas
