Sleeping Baby Safely
There's so much information out there on the best way to sleep your bub. However, it's often laced with judgement, opinion and scary stories, so we've decided to collect all the evidence and facts, so you can make an informed decision that best suits you and your family.
When you start to hear and talk about safe sleep, a national organisation called Red Nose Australia is often mentioned. According to their website, Red Nose was founded in 1977 by parents who had lost little ones to SIDS and SUDI and is "Australia's leading authority on safe sleep and safer pregnancy advice, and bereavement support for anyone affected by the death of a baby or child". Their advice, pamphlets and guidelines around sleep is generally the advice given to parents at the hospital by Doctors and Midwives, so you may see Red Nose at some point.
What are SIDS and SUDI?
SIDS [Sudden Infant Death Syndrome] is when a bub under the age of one year, who is otherwise healthy and has no underlying health concerns, passes away suddenly and unexpectedly in their sleep. For a death to be classified as SIDS, an autopsy and review of the circumstances around the death must show no obvious reason for the bub passing away.
SUDI stands for Sudden Unexplained Death in Infancy. SUDI is the term used when a bub passes away suddenly and unexpectedly, and the cause is no obvious straight away. An investigation will then be conducted. If a cause is not found, such as infection, overlaying whilst co-sleeping or metabolic disorders, the death is then re-classified as SIDS.
What are the current guidelines?
At this point in time, Red Nose currently recommends six guidelines when it comes to sleeping bubs under the age of one:
- Sleep bubs on their back to sleep, at every sleep.
- Keep bub's face and head uncovered.
- Keep baby smoke free before and after birth.
- Make sure the sleeping environment is safe at every sleep [day and night].
- Sleep your little one in a safe cot in your room for the first 6-12 months.
- Breastfeed bub.
- Putting your bub on their back to sleep helps keep their airway clear. Many mamas and papa-bears become scared that their bub will choke on their back, particularly if they get reflux. However, bubs have protective reflexes, where they will turn their head to the side to spit out the spew. Red Nose also says that sleeping bubs on their back actually helps to reduce the risk of suffocation, overheating and choking.
- Little ones control their temperature through their face and head. This means if a bub has a beanie, hat or blanket covering their head or face, they can't blow off that extra heat. Therefore, making sure bub's face and head are uncovered during sleep helps to reduce the risk of overheating. It also helps keep their airways clear as nothing can fall down and cover their mouth or nose, which reduces the risk of suffocation. This is also why it's recommended to sleep bub at the bottom of the cot or use a sleeping bag; so they can't wriggle down under the blankets.
- According to Red Nose, exposing bub to smoke after birth from people smoking around bub, smoking and then holding bub [including secondary smoke] or exposing bub while in a mama's tummy from a mama smoking increases the risk of sudden infant death.
- This recommendation is because bubs can pass away from SIDS or SUDI at any time of day or night during any nap or sleep- it's not always the long stretch of nighttime sleep. Making sure the sleep environment is always safe helps to maintain that risk reduction. Red Nose also advises making sure bub's cot and mattress meet the Australian standards, their bedding is lightweight, firmly tucked in and only pulled up to the chest, and sleeping bags are firm fitting around the neck and chest, hoodless and allow bubs arms to be free.
- The Red Nose safe sleeping handout doesn't provide a reason for this recommendation. However, we will touch again on this later.
- The Red Nose safe sleeping pamphlet reports that breastfeeding your little one reduces the risk of SIDS, and the website goes on to state that it decreases the risk by more than 50%. It also says that mamas who formula feed can decrease their SIDS risk by following the other five recommendations.
Red Nose also includes some things they recommend mamas, papa-bears, and anyone else caring for bub avoid using:
- Soft sleeping surfaces like adult mattresses or bean bags
- Soft items in the cot [pillows, teddies, lambswool or toys] because these increase the risk of overheating and suffocation.
- Cot bumpers
- Hoods/ hats/ beanies
- Any devices or inserts that are to be used inside cots that aren't part of the original cot itself or mattress
They also advise the following are unsafe sleep surfaces:
- Lounges or armchairs
- Adult beds
- Bean bags
- U shaped pillows
- Other baby products that are designed for uses other than sleeping, such as a DockATot
- In an adults arms or on their chest when they are also sleeping
I've been around mamas and bubs for long enough to know that some mamas will co-sleep with their bubs at some point. Co-sleeping is when a mama brings a bub into their bed and sleep alongside them. Some people have strong opinions for or against co-sleeping. It's not my job to judge. I just ask that if you co-sleep, do it safely. Here's how to do that, according to the Red Nose guidelines:
- Continue to sleep bub on their back.
- Tie up your hair if it's long, and remove jewellery [including amber teething necklaces].
- Place your little one beside one parent rather than in the middle.
- Bub should never co-sleep next to pets or other little ones in the bed.
- Keep your bed away from the wall to avoid bub getting trapped between your bed and the wall, but make sure they won't roll off too.
- Give bub their own space and keep your bedding separate and away from bub, including pillows, blankets and sheets.
- Avoid wrapping or swaddling bub when co-sleeping. Instead, use a safe sleeping bag with free arms and no hood.
- Make sure your little one's face and head remain uncovered throughout their sleep.
Despite all these risk-minimising strategies, there are some circumstances where co-sleeping is still considered not safe:
- When you or others in the bed are under the influence of alcohol or other drugs, that make you more sleepy than normal.
- You're really tired, sleep-deprived or sick.
- You or others in the bed smoke.
- Bub was born preterm, unwell or small.
To make an informed decision, you need to know what the research says, so I've summarised it here based on what Red Nose advises.
- Most bubs who pass away from SUDI are aged less than 3 months, born preterm or small. This is why some people recommend not bed-sharing until bub is at least 3mo.
- Sharing a sleep surface can increase the risk of SUDI.
- Strategies can be used to reduce the risks of bed-sharing.
- The majority of studies have shown a very high risk of infant death when a bub shares a lounge for sleep.
- There's a very high risk of a sleeping accident when a mama, papa bear or caregiver accidentally falls asleep on the lounge as bub may become wedged in the cushions or the back of the lounge.
- A caregiver falling asleep with bub on their tummy on a caregiver's chest can be risky. That's because tummy sleeping reduces bub's arousal mechanisms that protect the airway; their nose may be covered by clothing or a mama's body, or incorrect positioning may obstruct a bub's airway.
It's not all bad, though; there are also plenty of benefits, including:
- Improved breastfeeding outcomes
- Improved maternal sleep
- Increased infant arousals levels, which is SIDS protective [note: mamas and papa bears who bed-share report fewer infant sleep problems]
- Increased maternal bonding, responsiveness and protective maternal behaviours
- Improved settling, less crying and reduced stress response in bubs
- Increased likelihood of bub sleeping in the recommended supine [on the back] position
- Improved breastfeeding outcomes
- Reduced formula supplementation
- Higher self-esteem, better social skills and emotional outcomes for bubs in later life
As discussed earlier, overheating is a risk factor for SIDS. To try and avoid this, many mamas and papa-bears ask what room temperature they should sleep their bub in. At present, Red Nose doesn't recommend a specific room temperature for bub's room, leaving the heater or aircon on all night or monitoring the room temperature. Instead, they recommend dressing bub to the conditions of the room. As a general rule, you should dress bub as you would yourself; not too hot or cold. Some even say to dress bub in what you're wearing +1 layer. Electric blankets, heat packs or wheat bags shouldn't be used for little ones either.
When looking at the evidence, I came across something pretty interesting. A case-controlled study of 185 bubs who passed from SIDS and 312 other bubs who did not found that the use of a fan was associated with a 72% reduction in SIDS risk. This was even higher when the sleep environment wasn't safe. Researchers aren't sure how or why this works, but the theory is that the fan may reduce bub rebreathing their carbon dioxide, which could be trapped near their face by unsafe bedding.
There's no evidence that a specific room temperature prevents SUDI, and a bub's room or outside temperatures doesn't influence SIDS when bubs are sleeping on their back, dressed appropriately for the room temperature, and their head and face are uncovered. Bubs placed on their tummy to sleep are 60% less effective at blowing off extra heat than bubs who sleep on their back. Researchers also found that bubs who tummy sleep on a soft surface face a 20 times increased risk of SIDS compared to those who don't. But regardless if a bub sleeps on their tummy or back, if they have something covering their face, research shows those bubs will experience more frequent drops in oxygen levels and decreased arousal levels, which is a protective mechanism of SIDS.
There are many breathing monitors out there on the market. Many mamas and papa bears often wonder, "do I need a breathing monitor?"
The short answer is, according to research, using a breathing monitor will not prevent SIDS from occurring. There may be some situations where a doctor may recommend a breathing monitor for a bub. However, this is not often the case.
Some mamas and papas find that the peace of mind the device gives them helps them sleep, while others find that false alarms increase their anxiety. A concern that many in the medical profession hold is that while the device may alarm, it's not going to provide CPR or save bub's life; you still need those skills if that's the situation that is unfolding. The general recommendation around breathing monitors is that they aren't indicated for healthy, well bubs, but in my opinion, if that device makes you sleep, you know what to do if it ever did go off and you realise that it's not fool-proof [there may be instances where it alarms inaccurately or doesn't alarm when it should], then go for it! You do what you need to do to be a better mama or papa bear, and if that's a sleep monitor, then so be it.
Some mamas and papa bears have more than one little love to consider. When it comes to creating a safe sleeping surface for twins, the same six principles apply. Twins should always be in their own cot, following the guidelines above. While in hospital, some twins may be put in the same cot while closely monitored. Current research doesn't sway for or against this practice while in hospital, but at home, it's recommended twins must be in their own cot.
In some circumstances, it may not be possible for twins to share a cot. In those cases, the guidelines are:
- Sleep one twin at either end of the bed.
- Avoid any bedding; instead, use safe sleeping bags.
- Continue to follow the other six principles.
- If either twin is freely moving around the cot, they shouldn't share at all.
Babywearing is when a mama, papa bear or carer carries a bub on their tummy or back using a sling, wrap or baby carrier. There's plenty of evidence showing the benefits of babywearing, and the effects it has on infant development. The reason it's being mentioned here is because a recent Australian study showed that more than 33% of bubs had slept in an infant carrier in the first 3-4 months of life. While there's no evidence of adverse events happening when used correctly, not everyone knows the principles of using them to keep bub safe.
The recommended principals to follow when babywearing is TICKS.
T= Tight enough so bub won't slump, but not too tight that they can't breathe normally.
I= In view at all times. You should be able to look down and see bub's face, nose and mouth at all times.
C= Close enough to kiss. Bub's head should be close enough to kiss.
K= Keep bub's chin off their chest because this position can restrict breathing. It also helps avoid them getting into a 'C' position, which is unsafe in baby carriers.
S= Supported back. Your little one's back should be in a natural position with their tummy and chest pressing against you.
After doing some more digging, I found the evidence which forms the recommendations for room sharing.
According to Red Nose, several studies have shown that when a caregiver [mama, papa bear or someone looking after bub] shares a room with bub, but not a sleep surface, their SIDS risk is reduced by up to 50% compared to little ones who sleep in a separate room. This may be based on research of nighttime mama-bub interactions, which showed that mamas and bubs who slept together experience increased physical contact, more breastfeeds and increased arousals overnight, which is SIDS protective, compared to bubs who slept in their own rooms. Interestingly, that protective factor isn't the same when bubs room share with siblings instead of mamas, papa bears or caregivers.
In saying that, there are some mamas and papa bears who simply can't sleep with bub in the same room. If this is you, please don't feel bad, and my advice would be to follow the other five principles of SIDS minimisation.
As you can see, there's lots of advice, recommendations and areas to discuss when it comes to sleeping. Do your research, and work out what works best for you and your little one. And don't ever forget, you're doing a great job, mama.