Sudden Infant Death Syndrome—New recommendations
The American Academy of Pediatrics has published new SIDS prevention
recommendations that can affect child care providers who care
for infants. These include new guidelines on side-sleep positions,
pacifiers, soft bedding, and plagiocephaly (misshapen or flattened
What is SIDS?
SIDS is the leading cause of death in infants in the United States—5,000
to 6,000 deaths a year. Almost 20 percent of those deaths occur
in child care programs.
SIDS is defined as the sudden death of a previously healthy baby
younger than 1 year old. It’s identified as the cause of
a death that is unexplained after a thorough case investigation
including autopsy, death scene investigation, and medical history.
SIDS is a diagnosis of exclusion. This means that a SIDS diagnosis
is made only after all factors including injury and illness that
could contribute to the death are ruled out.
SIDS has been described as a syndrome in search of a cause. SIDS
rates have dropped dramatically since 1992 when parents and other
caregivers were urged to place infants on their backs for sleep.
But unfortunately, the syndrome is complex and not always caused
by the same factors or conditions.
Causes of SIDS
In the medical science world, a theory (an educated and considered
guess) must be researched, studied, and formalized. The theory
might be based on the evaluation of medical records, demographics,
and anecdotal records.
In 2006, researchers determined that abnormalities in a part
of the brain that controls breathing and arousal likely play
a role in SIDS. Other current research points to heart disturbances
and genetic defects and examines environmental factors like the
impact of pacifiers and ceiling fans.
At the same time, experts have discounted several early causation
theories including suffocation, choking, birth injury, and infection.
After years of study, researchers have developed a triple-risk
model to describe the factors that can cause SIDS. Today, most
experts believe that an infant at a critical
developmental stage (the first six months of life) must have a biological
vulnerability (an undetectable brain, heart, or genetic defect, for example)
and an environmental stressor (soft bedding, for example) for
SIDS to occur.
Risk factors for SIDS
While any infant can die from SIDS, several behaviors and conditions
seem to increase the risk. Researchers and physicians have
identified risk factors to guide the care of infants. However,
these factors do not account for all SIDS deaths and, indeed,
some babies seem to be unaffected by them.
Factors that put babies at greater risk for SIDS include the
Age and sex—male babies younger than 6 months are most
Race—Black and American Indian babies are at twice the
risk due to genetic and behavioral factors;
Premature birth and low birth weight;
Sleep position—stomach and side sleeping positions put
babies at high risk;
Sleep environment—sharing a bed, soft surfaces, and fluffy
bedding increase risk;
Cold weather—there are more SIDS deaths in the winter
Unaccustomed tummy sleeping—if the infant usually sleeps
on the back and then is placed on the tummy for sleep, there
is as much as an 18 times greater risk; and
Specific maternal characteristics and behaviors—a mother’s
young age, smoking, binge drinking during pregnancy, and limited
or absent prenatal care are all identified as putting babies
The AAP has issued the following recommendations:
positions: Multiple studies have demonstrated that side
position for sleep places infants at higher risk for SIDS than
the preferred back (supine) position. Side sleep positions are
unstable; the infant is likely to flop to the unaccustomed prone
(tummy) position. Babies at highest risk for SIDS (18 percent
higher than consistent back sleepers) are those who usually sleep
on the back but are placed on the tummy or roll onto the tummy
Babies typically begin comfortably and consistently to roll from
back to tummy by 6 months of age. Generally the risk of SIDS
diminishes after this developmental milestone is reached. The
AAP says that you don’t have to shift sleeping babies who
roll to their tummies if all other risk factors have been minimized.
Parents often voice concern about the danger of choking or aspiration
when babies sleep on the back. Healthy babies who spit up will
not choke. Research shows that there is no increased risk of
aspiration for babies who sleep on their backs.
Pacifiers: Studies consistently demonstrate the protective effect
of pacifiers. The specific mechanisms involved in this protection
are unknown, but it’s clear from the research that there
is a reduction in the risk of SIDS even when the pacifier falls
out of the mouth when the baby falls asleep.
There are downsides, however. These include dental malocclusion
(for toddlers who don’t give up the pacifier by age 3),
(twice the risk of ear infection), gastrointestinal
infections, and oral Candida (likely related to lax sanitation
If the infant is being breastfed, it’s best to wait until
the baby is at least 1month old before introducing a pacifier
to help ensure the firm establishment of breastfeeding. If the
baby refuses the pacifier, don’t force it. If the pacifier
is useful, use it when the baby is falling asleep. Don’t
reinsert it after the baby is asleep, don’t coat it with
sweetener, and don’t put it in your mouth. Clean and replace
bedding: Infants who die from SIDS are more likely to be
sleeping in a prone position (face down) and have soft mattresses
and bedding that cover the nose and mouth.
A baby’s crib should be safety-approved with slats spaced
not more than 2 3/8 inches apart. The mattress should fit snugly
in the crib and have a tight-fitting sheet. Chairs, sofas, water
beds, cushions, and adult beds are not safe sleep surfaces for
Excess bedding—pillows, bumper pads, blankets, quilts,
and plush toys—can impair the baby’s ability to breathe
if they cover the face. Wearable blankets or sleep sacks are
safer than blankets if extra warmth is needed.
If you use a blanket, use the recommended technique.
Place the baby’s feet against the foot of the crib and
tuck the blanket under the baby’s arms and along the sides
and foot of the crib. This technique keeps the baby from scooting
under the blanket and covering the head.
The AAP discourages the use of wedges and positioners. Bumper
pads are not necessary.
Plagiocephaly: Because a newborn’s skull is soft and pliable,
back sleeping can contribute to a flattening on the back of the
head (positional plagiocephaly). This condition is generally
temporary. As babies grow and become more active, their skulls
Babies spend much of their time in bouncy seats, infant carriers,
strollers, and car safety seats. Each of these exerts constant
pressure on the back of the head, especially in the youngest
babies who tend to fall asleep in these chairs.
When you place an infant on the back to sleep, alternate the
direction the head faces, causing the baby to look left or right.
The AAP recommends supervised tummy time for awake babies and
holding awake babies upright to help decrease the constant pressure
on the back of the head. Tummy time is essential to muscle strength
and development. Interact with babies during tummy time for short
periods three to four times a day, increasing the amount of time
gradually as the baby’s strength increases.
Safe sleep practices
Because the safety of children is your highest priority, it’s
wise to formalize your program’s policies for safe sleeping
practices. Share these procedures with families, and ask for
a parent’s or guardian’s signature to reinforce cooperation
(and protect you in the case of SIDS). A formal policy will help
maintain quality standards, guide teacher training and expectations,
and reassure parents that their baby’s health is paramount.
Use the following guidelines in establishing safe sleep policies
for your program.
Put babies to sleep on the back. The AAP and local health authorities
have brochures and posters reinforcing “Back is best.”
Obtain a physician’s note for non-back sleepers. Make
sure the directive describes the prescribed sleep position, the
reason for not using the back position, a time frame for the
directive, and the physician’s signature. Keep a copy of
the note in the baby’s file and post one on the baby’s
Maintain a smoke-free environment.
Use safety-approved cribs and firm mattresses.
Keep the crib free of anything but the baby.
If you use blankets, practice the feet-to-foot rule.
Sleep only one baby per crib.
Maintain room temperature that prevents overheating (comfortable
for a lightly clothed adult). If a baby is sweating around the
neck or face, it probably means fever and illness. When this
happens, use fewer covers—not more.
Monitor sleeping babies.
Schedule tummy time for babies when they are awake.
Avoid apnea monitors and other marketed SIDS-prevention devices.
They are costly and unlikely to prevent a SIDS death.
Second Edition. 2002. Elk Grove Village, Ill.: American Academy
American Academy of Pediatrics. Healthy Child Care America Back
to Sleep Campaign. www.healthychildcare.org/section_SIDS.cfm.
National Institute of Child Health and Human Development. Back
to Sleep Campaign. www.nichd.nih.gov/sids.