SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment

1. Infants should be placed for sleep on the back (face up) for every sleep by every caregiver until the child reaches 1 year of age.
  • Sleeping on the side or stomach can increase the risk of rebreathing exhaled gas, resulting in decreasing oxygen level and increased carbon dioxide level.
  • Sleeping on the stomach can also increase the risk of overheating and alters the nervous system control of the cardiovascular system which may result in decreased oxygen delivery to the brain.
  • Also, from an anatomic perspective, when a baby is on his/her back the tube to the stomach is below the tube to the lungs. If a baby were to spit up, the spit up would have to work against gravity to get into the lungs. When a baby is on his/her stomach, spit up can flow more easily into the lungs, making it easier for the baby to aspirate or choke.

Image courtesy of the Safe to Sleep:registered: campaign needs to be under the anatomic drawing


Image courtesy of the Safe to Sleep® campaign

once a baby can roll, they often will chose to sleep in another position. If a baby can roll both front to back and back to front, while we still recommend placing an infant on the back, if they roll to another position, they can remain- but be very cautious to keep the sleep space clear of any objects that your baby could roll onto. If they can only roll from back to stomach then I often recommend repositioning them onto their back during sleep until they learn to roll back onto their back. Increased tummy time during the day will to help them learn this skill.

Yes! In this photo the baby is placed on his back. This is recommended to help reduce the risk of SIDS.

Not Safe

No! In this photo the baby is not placed to sleep on his back. This is an unsafe sleeping situation. Sleeping on the back is safer than sleeping on the side or on the stomach. Positioners and wedges should not be used in the bed. Also, hats can lead to overheating.

View References

Tuffnell CS, Petersen SA, Wailoo MP. Prone sleeping infants have a reduced ability to lose heat. Early Hum Dev. 1995;43(2):109–116
Ammari A, Schulze KF, Ohira-Kist K, et al. Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants. Early Hum Dev. 2009;85(8):497–501
Kanetake J, Aoki Y, Funayama M. Evaluation of rebreathing potential on bedding for infant use. Pediatr Int. 2003;45(3):284–289
Kemp JS, Thach BT. Quantifying the potential of infant bedding to limit CO2 dispersal and factors affecting rebreathing in bedding. J Appl Physiol (1985). 1995;78(2):740–745
Kemp JS, Livne M, White DK, Arfken CL. Softness and potential to cause rebreathing: differences in bedding used by infants at high and low risk for sudden infant death syndrome. J Pediatr. 1998;132(2):234–239
Patel AL, Harris K, Thach BT. Inspired CO(2) and O(2) in sleeping infants rebreathing from bedding: relevance for sudden infant death syndrome. J Appl Physiol (1985). 2001;91(6):2537–2545
Yiallourou SR, Walker AM, Horne RS. Prone sleeping impairs circulatory control during sleep in healthy term infants: implications for SIDS. Sleep. 2008;31(8):1139–1146
Wong FY, Witcombe NB, Yiallourou SR, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics. 2011;127(3). Available at: www. pediatrics. org/ cgi/ content/ full/127/ 3/ e558


2. Infants should be placed on a firm sleep surface (eg, mattress in a safety-approved crib) covered by a fitted sheet with no other bedding or soft objects to reduce the risk of SIDS and suffocation.

Soft mattresses, including mattress toppers and memory foam, or sheepskin, could create a pocket (or indentation) and increase the chance of rebreathing or suffocation if the infant rolls onto the stomach
References: Kemp JS, Livne M, White DK, Arfken CL. Softness and potential to cause rebreathing: differences in bedding used by infants at high and low risk for sudden infant death syndrome. J Pediatr. 1998;132(2):234–239
Kemp JS, Nelson VE, Thach BT. Physical properties of bedding that may increase risk of sudden infant death syndrome in prone-sleeping infants. Pediatr Res. 1994;36(1 pt 1):7–11

A firm surface maintains its shape and will not indent or conform to the shape of the infant’s head when the infant is placed on the surface.

A firm surface maintains its shape and will not indent or conform to
the shape of the infant’s head when the infant is placed on the surface.

Yes! In this photo the baby is placed on a firm sleep surface with a fitted sheet designed for this mattress. Note the baby’s head does not cause an indentation into the mattress.

Not Safe

No! This is an unsafe sleeping situation. The baby is on a soft mattress. His head causes an indentation into the mattress. Additionally the baby has loose blankets and a hat (head covering). Both of these raise the risk for SIDS

What exactly is a safety approved crib? It is a crib or bassinet that meets the CPSC standards. They have a website at CPSC.gov. Unfortunately, I haven’t found a way to look up cribs/bassinets at this website, so I reached out to them. The mail response I received From CSPC Hotline is here: “The manufacturer or importer must provide a Children’s Product Certificate (CPC) that certifies that the children’s product complies with all applicable children’s product safety rules ( or similar rules, bans standards or regulations under any law enforced by the Commission for that product.) The certificate must be provided to the retailers. You can contact the manufacturer of the product for the information. The standards that applies to cribs is 16 CFR 1219.1, 1219.2 and 1220. For bassinets, it is 16 CFR Part 1218.” (Email received 12/28/2017)


3. If able, breastfeed exclusively until 6 months. Breastfeeding is associated with a reduced risk of SIDS.

Infant sleep studies showed that breastfed infants are more easily aroused from sleep than their formula-fed counterparts. In addition, breastfeeding results in immune system benefits and decreased incidence infectious diseases/illnesses that are associated with an increased vulnerability to SIDS

View References

Franco P, Scaillet S, Wermenbol V, Valente F, Groswasser J, Kahn A. The influence of a pacifier on infants’ arousals from sleep. J Pediatr. 2000;136(6):775–779
Horne RS, Parslow PM, Ferens D, Watts AM, Adamson TM. Comparison of evoked arousability in breast and formula fed infants. Arch Dis Child. 2004;89(1):22–25
Heinig MJ. Host defense benefits of breastfeeding for the infant: effect of breastfeeding duration and exclusivity. Pediatr Clin North Am. 2001;48(1): 105–123, ix
Kramer MS, Guo T, Platt RW, et al. Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. Am J Clin Nutr. 2003;78(2):291–295


4. It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

The theory is two-fold:
-The parents are more aware of the infants well being and able to respond quickly if needed. Infant monitors to not seem to provide the same protection.
-The baby is more easily aroused from sleep he/she may sleep lighter due to the noises the parents make during their own sleep.

We were unable fit a crib in our bedroom. We used a bassinet until the baby turned 4 months of age, and then changed into a travel crib in our bedroom, and then moved into the crib in a separate room at age 1.


5. Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and Strangulation.

The most significant risk factor for sleep-related deaths in infants >4 months of age was rolling onto objects in the sleep environment.

Watch out for cords and blinds/shades which a baby can reach for and become fatally entrapped. Keep toys and other soft items out of the sleep environment. This includes blankets, “lovies”, quilts, stuffed animals, pacifiers with animals attached to them and bumpers, including mesh bumpers. There are no safe bumpers. Said another way- the only thing that goes in the crib is the baby. If in doubt, keep it out!

View References

Colvin JD, Collie-Akers V, Schunn C, Moon RY. Sleep environment risks for younger and older infants. Pediatrics. 2014;134(2). Available at: www.pediatrics.org/cgi/content/full/134/2/e406


6. Use a pacifier

It’s not clear, but there may be improved nervous system control or improve the positioning of the airway during sleep.

If a baby won’t take a pacifier, don’t force it.  If the baby takes the pacifier and later spits it out, you don’t need to replace it.
Using a pacifier in very early infancy can cause difficulty with latching for breastfeeding. Breastfeeding is also an important way to decrease the risk of SIDS, so what I often recommend is introducing the pacifier once the mom-baby pair have established a good breastfeeding routine and consistent latch, this is usually around 2 weeks of age.

View References

Franco P, Chabanski S, Scaillet S,Groswasser J, Kahn A. Pacifier use modifies infant’s cardiac autonomic controls during sleep. Early Hum Dev. 2004;77(1-2):99–108
Tonkin SL, Lui D, McIntosh CG, Rowley S, Knight DB, Gunn AJ. Effect of pacifier use on mandibular position in preterm infants. Acta Paediatr. 2007;96(10):1433–1436


7. Avoid smoke exposure during pregnancy and after birth.

Smoking during pregnancy is a major risk factor for SIDS. Smoke in the infant’s
environment limits an infant’s arousal. Up to ⅓ ​of SIDS deaths could be
prevented if all maternal smoking during pregnancy was eliminated

View References

MacDorman MF, Cnattingius S, Hoffman HJ, Kramer MS, Haglund B. Sudden infant death syndrome and smoking in the United States and Sweden. Am J Epidemiol.1997;146(3):249–257
Schoendorf KC, Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy. Pediatrics. 1992;90(6):905–908
Malloy MH, Kleinman JC, Land GH, Schramm WF. The association of maternal smoking with age and cause of infant death. Am J Epidemiol. 1988;128(1):46–55
Haglund B, Cnattingius S. Cigarette smoking as a risk factor for sudden infant death syndrome: a population-based study. Am J Public Health. 1990;80(1):29–32
Tirosh E, Libon D, Bader D. The effect of maternal smoking during pregnancy on sleep respiratory and arousal patterns in neonates. J Perinatol. 1996;16(6):435–438
Franco P, Groswasser J, Hassid S, Lanquart JP, Scaillet S, Kahn A. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants. J Pediatr. 1999;135(1):34–38
Horne RS, Ferens D, Watts AM, et al. Effects of maternal tobacco smoking, sleeping position, and sleep state on arousal in healthy term infants. Arch Dis Child Fetal Neonatal Ed. 2002;87(2):F100–F105
Sawnani H, Jackson T, Murphy T, Beckerman R, Simakajornboon N. The effect of maternal smoking on respiratory and arousal patterns in preterm infants during sleep. Am J Respir Crit Care Med. 2004;169(6):733–738
Lewis KW, Bosque EM. Deficient hypoxia awakening response in infants of smoking mothers: possible relationship to sudden infant death syndrome. J Pediatr. 1995;127(5):691–699
Chang AB, Wilson SJ, Masters IB, et al. Altered arousal response in infants exposed to cigarette smoke. Arch Dis Child. 2003;88(1):30–33
Parslow PM, Cranage SM, Adamson TM, Harding R, Horne RS. Arousal and ventilatory responses to hypoxia in sleeping infants: effects of maternal smoking [published correction appears in Respir Physiol Neurobiol. 2004;143(1):99]. Respir Physiol Neurobiol. 2004;140(1):77–87
Mitchell EA, Milerad J. Smoking and the sudden infant death syndrome. Rev Environ Health. 2006;21(2):81–103 300.
Dietz PM, England LJ, Shapiro-Mendoza CK, Tong VT, Farr SL, Callaghan WM. Infant morbidity and mortality attributable to prenatal smoking in the U.S. Am J Prev Med. 2010;39(1):45–52


8. Avoid alcohol and illicit drug use during pregnancy and after birth.

9. Avoid overheating and head covering in infants.

A baby should be dressed appropriately for the environment with no more than 1 layer more than an adult would wear in the same situation. A baby is considered overheated if the baby is sweating or if the infant’s chest feels hot to the touch. Avoid covering the head or face, as this can lead to overheating (and suffocation)


10. Pregnant women should obtain regular prenatal care.

11. Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention.

Several large studies have found vaccines to be protective against SIDS. There is a decreased risk of SIDS immediately after vaccination, which might simply be linked to infants typically being healthy at the time of vaccination.

View References

Mitchell EA, Stewart AW, Clements M; New Zealand Cot Death Study Group. Immunisation and the sudden infant death syndrome. Arch Dis Child. 1995;73(6):498–501
Jonville-Béra AP, Autret-Leca E, Barbeillon F, Paris-Llado J; French Reference Centers for SIDS. Sudden unexpected death in infants under 3 months of age and vaccination status—a case-control study. Br J Clin Pharmacol. 2001;51(3):271–276
Fleming PJ, Blair PS, Platt MW, Tripp J, Smith IJ, Golding J. The UK accelerated immunisation programme and sudden unexpected death in infancy: case-control study. BMJ. 2001;322(7290):822
Müller-Nordhorn J, Hettler-Chen CM, Keil T, Muckelbauer R. Association between sudden infant death syndrome and diphtheria-tetanus-pertussis immunisation: an ecological study. BMC Pediatr. 2015;15:1
Virtanen M, Peltola H, Paunio M, Heinonen OP. Day-to-day reactogenicity and the healthy vaccinee effect of measles-mumps-rubella vaccination. Pediatrics. 2000;106(5). Available at:www.pediatrics.org/cgi/content/full/106/5/e62


12. Avoid the use of commercial devices that are inconsistent with safe sleep recommendations.

This includes recliners, many “sleepers” including the very popular “rock-n-play” and loungers such as the “doc-a-tot” which, unfortunately are not safe sleeping surfaces. Wedges and sleep positioners are often made of soft materials and have been associated with cases of infant death. Also, falling asleep in a swing or carseat puts an infant at higher risk for SIDS and they should be moved to a safe sleep surface as soon as practical.


13. Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.

They just haven’t been shown to help, and maybe could decrease parental vigilance due to a false sense of security.

Like all parents, I was worried about SIDS and decided to use a monitor, we had a false alarm the first night we used it that brought us into urgent care just to make sure he was OK.


14. Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional Plagiocephaly.

Some babies don’t like tummy time. Propping the arms up under the collarbone can help them lift their head up, so they can enjoy tummy time a little easier. Also, babies don’t have to be on the floor to count as tummy time. As long as they are awake, on their tummy and lifting their head, it counts.

Pushing the hands up under the collerbone helps babies lift their head up more easily.

Toys certainly make tummy time easier.

This counts as tummy time too!


15. There is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS

16. Health care professionals, staff in newborn nurseries and NICUs, and child care providers should endorse and model the SIDS risk-reduction recommendations from birth

17. Media and manufacturers should follow safe sleep guidelines in their messaging and advertising.

Point it out when you see unsafe sleep. If you need help, check out the advocacy letters that you can print off and send- you never know when you may save a life!


18. Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths, including SIDS, suffocation, and other unintentional deaths. Pediatricians and other primary care providers should actively participate in this campaign.

19. Continue research and surveillance on the risk factors, causes, and pathophysiologic mechanisms of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths altogether.

Join the effort to educate

I am also hoping to harness the power of our users to join in the effort educate parents, caretakers, leaders and media to encourage normalizing safe sleep practices in marketing materials, movies, and all forms of media. Together, we can save babies!

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