Safe Sleep and Reducing SIDS Risk

The essentials

The NHS adds two details. Put your baby down in the feet-to-foot position — feet at the bottom of the cot, Moses basket or pram. And keep the cot clear: "do not use pillows, duvets, cot bumpers, loose blankets, soft toys or anything to keep your baby in place, like pods or nests." If your baby was born prematurely, follow safer sleep advice "for a year from their due date not the date they were born."

The CDC reports that "in 2022, about 3,700 babies died suddenly and unexpectedly in the United States", and says it "supports the 2022 recommendations issued by the American Academy of Pediatrics." The NHS notes SIDS is most likely in the first 6 months but can affect babies up to 12 months, and that babies born before 37 weeks or under 2.5 kg (5.5 lb) are at higher risk.

Sleep position

Back, every time. The AAP: "Babies who sleep on their backs are much less likely to die suddenly and unexpectedly than babies who sleep on their stomachs or sides. The problem with the side position is that your baby can roll more easily onto their stomach."

Room-sharing is the single most effective addition: the AAP says it "can decrease the risk of SIDS by as much as 50%".

On choking, the fear that drives most deviation: the AAP says "your baby's airway anatomy and their gag reflex will keep that from happening", and adds that "even babies with gastroesophageal reflux disease (GERD) should sleep flat on their backs." If your baby rolls, move them onto their back until they can roll both ways by themselves (NHS).

The sleep surface

The AAP's definition is precise: "A firm surface means that it shouldn't indent when your baby is lying on it. Any surface that inclines more than 10 degrees isn't safe for your baby to sleep on."

• Use a cot, bassinet, portable cot or play yard meeting your country's safety standards, with a tightly fitting mattress and a fitted sheet only.
• Do not use products for sleep that are not marketed for infant sleep — the AAP names nursing pillows and lounger-style products — or weighted blankets, sleepers or swaddles.
• If your baby falls asleep in a car seat, pram, swing, carrier or sling, move them to a firm flat surface on their back as soon as possible.

Temperature

Check by feeling your baby's chest or the back of their neck. The NHS: "Do not worry if their hands or feet feel cool, this is normal." Sweating, a hot chest or flushed skin means remove a layer. The AAP's rule of thumb is one more layer than you would wear yourself, and no hat indoors. Never a hot water bottle, electric blanket, radiator, fire or direct sunlight.

Bed-sharing: what the guidance actually says

Sources genuinely differ here, and it deserves stating honestly.

The AAP does not recommend bed-sharing at all: "Based on the evidence, the AAP doesn't recommend bed sharing with your baby under any circumstances. This includes twins and other multiples." If you bring your baby into bed to feed or comfort them, put them in their own sleep space before you sleep.

UK and Irish guidance takes a risk-reduction approach, because some parents will bed-share whatever the advice, and falling asleep on a sofa while trying to avoid the bed is far more dangerous.

When bed-sharing is never safe

The Lullaby Trust says co-sleeping is "very dangerous if":

• "You or anyone in the bed has recently drunk any alcohol." The NHS and NICE both set the threshold at 2 or more units.
• "You or anyone in the bed smokes or the baby was exposed to smoking in pregnancy." The NHS adds: no matter where or when you smoke, and even if you never smoke in bed.
• "You or anyone in the bed has taken any drugs or medication that make you feel sleepy."
• "Your baby was born prematurely (before 37 weeks of pregnancy) or weighed under 2.5kg (5.5 lb)."

NICE (NG194) uses almost identical wording, and Raising Children Network adds two more circumstances: when you are extremely tired or unwell, and when your baby is unwell.

And regardless of any of that: never on a sofa or armchair. The AAP quantifies it — "the risk of sleep-related infant death is up to 67 times higher when infants sleep with someone on a couch, soft armchair or cushion."

If you do bed-share, what makes it safer

The Lullaby Trust and the NHS give the same list:

• Baby on their back, on a firm flat mattress.
• "Keep pillows and adult bedding away from your baby, along with any other items that could cover their head or cause them to overheat."
• Do not swaddle your baby in bed — the NHS says baby sleeping bags are safer.
• No other babies, children or pets in the bed.
• "Never leave your baby alone in an adult bed." If no adult is in it, move them to a cot, crib or Moses basket.
• Make sure your baby cannot fall out, or become trapped in the bedframe or between the mattress and the wall. "Remove slatted or decorated headboards."
• Raising Children Network adds: put the baby to the side of one parent rather than between two adults, and tie long hair back.

The other things that lower the risk

• Breastfeeding. The AAP: "the longer you give your baby breast milk, the more protection it gives."
• A dummy at nap time and bedtime. The NHS: "some research suggests this can help lower the risk of SIDS." Wait until breastfeeding is established, and never hang a dummy round your baby's neck or attach it to their clothing during sleep.
• Vaccinations, which the NHS says "provide protection against childhood illnesses that may increase the risk of SIDS", and antenatal care (AAP).
• Supervised tummy time while awake, building to at least 15 to 30 minutes a day by 7 weeks (AAP).
• Slings used safely. The NHS recommends the T.I.C.K.S. rules: tight; in view at all times; close enough to kiss; keep the chin off the chest; support the back upright.

What does not work

• Swaddling does not reduce SIDS risk. If you swaddle, always place your baby on their back, keep it loose enough for breathing and hip movement, and stop as soon as your baby looks like they are trying to roll — usually around 3 to 4 months.
• Home monitors do not reduce SIDS risk. The AAP: "there is no evidence that these devices... decrease SIDS risk. Don't let them give you a false sense of security." Nor does any product claiming to: "There's just no evidence that this is true."

When to call

Call your local emergency number (999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, 111 in New Zealand) if your baby stops breathing or is struggling for breath, will not wake up, is stiff, shaking or jerking, is limp or floppy or not responding as they normally do, or if their lips, tongue, face or skin suddenly turn pale, blue or grey — on black or brown skin this may be easier to see on the palms or soles.

Get an urgent GP appointment or contact your out-of-hours line if you are worried about your baby or think they might be ill. If you have been bereaved by SIDS, The Lullaby Trust runs a helpline on 0808 802 6868 and offers bereavement support.