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Protecting Your Baby from SIDS

Up close of baby with pacifier, lying down

Now that she has children of her own, Susan Sorensen, MD, a pediatrician in Reno, Nevada, offers her advice with a dose of reality. She understands, for instance, that some newborns really do like to be held all the time, and that it's not worth battling an 18-month-old who wants a pacifier morning, noon, and night. These days, she is unwavering on only a couple of issues. One of them is "back to sleep," the practice of putting babies to bed on their back (also known as the supine position). It's the sleep position that, since 1992, the American Academy of Pediatrics (AAP) has recommended for babies as an important way to reduce a baby's risk of sudden infant death syndrome (SIDS).

Back Sleep Is Best

"It's non-negotiable," says Dr. Sorensen. "When a parent tells me that her baby 'won't' sleep any other way but on its stomach, I literally can't listen." Pediatrician David Zucker, MD, Sorensen's first medical partner, influenced her position on the issue: "During my first 20 years in practice, I got about six calls a year from the coroner," says Dr. Zucker, who is also in Reno. "I would be called to patients' homes to examine babies who had died for no obvious reason," he says. "When the back-to-sleep guidelines first came out, I was skeptical that the number of crib deaths would decrease," he admits. "But the fact is, the numbers are lower, and I can't remember the last time I had one of those calls," he says.

Dr. Sorensen says she still frequently has parents who protest her back-to-sleep recommendation. "When parents insist that an older child slept on his stomach and was 'fine,'" she says, "all I can say is, 'You were lucky.'"

As most parents know, SIDS is the unexplained death of an infant younger than 1 year. Babies who are younger than 6 months -- when 90 percent of SIDS deaths occur -- are particularly vulnerable. And even though the back-to-sleep campaign of more than a decade ago has decreased the incidence of SIDS deaths by more than 50 percent, SIDS remains the number one cause of infant death in the United States. In fact, some 2,500 babies die from SIDS every year in this country, according to the National Institutes of Health.

What is especially troubling to experts is that no one really knows what causes it. "Most babies who die of SIDS appear perfectly normal," says Rachel Moon, MD, a pediatrician at Children's National Medical Center, in Washington, D.C., and a member of the AAP's SIDS Task Force. There is some speculation that babies who die of SIDS have an abnormality in the neural network that controls blood pressure, breathing, and temperature regulation, she explains. Or these babies may not produce adequate serotonin, a brain chemical that transmits nerve impulses that would cause a baby who wasn't getting enough oxygen to wake up.

"We do know that there are demographic and environmental risks," Dr. Moon says, noting that African-American and Native American babies die of SIDS at two to three times the national average, for example, and babies who are born to women who smoked during pregnancy or to very young women are at a higher risk. Preterm and low birth weight infants are also at higher risk. "But no baby is absolutely safe from SIDS," says John Kattwinkel, MD, chair of the AAP's SIDS Task Force.

What worries experts are parents like Stacy Ruskuski, of Brick, New Jersey, who weigh the odds and decide that because they don't fall into any of the high-risk categories, their babies will be safe sleeping on their stomach or side. "We tried putting our baby on his back for the first three or four weeks, but he would just cry and cry," Ruskuski says. After that, she put her son down on his stomach and he started sleeping contentedly -- by 3 months, he slept for 10 hours a night. However, this solution is risky: According to the American SIDS Institute, babies who sleep on their tummy have almost 13 times the risk of death as babies who sleep on their back.

Indeed, babies do sleep more soundly on their tummy, says Dr. Moon, which may prevent them from awakening when they're not getting enough oxygen, or it may allow them to re-breathe too much carbon monoxide, which can be deadly. Parents who fear that a baby who sleeps on her back is more susceptible to aspirating vomit need not worry. "That virtually never happens," says Dr. Moon, "and in fact, babies who sleep on their stomach are much more likely to choke on vomit than babies who sleep on their back."

With the goal of continuing to reduce the number of SIDS deaths, the AAP published its latest policy statement on SIDS in November 2005 (visit aap.org to view the statement in its entirety). Here is what you need to know to keep your baby safe:

"Back to sleep" -- always. Infants should be placed for sleep in the supine position, both for naps and nighttime sleep. "Until recently, we thought that side-sleeping was a reasonable alternative to back-sleeping, but now we know it is not," says Dr. Kattwinkel. "We have a number of studies showing that the side-sleeping position is unstable and increases a baby's chance of rolling onto his stomach," he says. In fact, one 2000 study found that the risk of SIDS for side-sleeping babies is similar to the risk for stomach-sleepers.

Share your room -- but not your bed -- with baby. There is growing evidence that having your baby's crib or bassinet in your room reduces the risk of SIDS. Members of the SIDS Task Force suggest placing a bassinet or crib next to your bed or in your room for at least the first six months of the baby's life. "That seems to the most protective sleep setting," says Dr. Moon. When babies are in the same room as a parent, she explains, they don't fall into as deep a sleep as they do when they're alone in the nursery. "Babies stir at the noises the parents make," she says, "and these frequent awakenings are protective." It's fine to breastfeed or hold your baby in your bed, says Dr. Moon, "but you should return your baby to his bassinet or crib when you're ready to go back to sleep."

As for bed-sharing, Dr. Moon discourages the practice. "We use soft mattresses and typically lots of pillows and bedding in this country," she says, "and a baby in a parents' bed is at risk for suffocation, overheating, strangulation, entrapment, and falls."

Don't overdress your baby. Some researchers believe that a baby who is too warm falls into such a deep sleep that it is difficult for him to awaken if he is in trouble. A bodysuit and a blanket sleeper are generally sufficient.

Breastfeed. Babies who are breastfed are more easily roused from sleep than formula-fed babies, which may be a reason breastfed babies are less likely to die from SIDS. Mothers who breastfeed are also less likely to smoke, and a baby's exposure to smoke -- both in the womb and secondhand -- increases the risk for SIDS.

Give your baby a pacifier. Using a pacifier lowers the risk of SIDS by about two-thirds, says Dr. Moon. "We don't know why yet," she says, "but it may be that sucking on a pacifier brings a baby's tongue forward, which opens the airway a little bit more." Or it could be that babies who use pacifiers don't fall into as deep a sleep as babies who don't. By the way, you needn't reinsert the pacifier if it falls out of your baby's mouth; while the reasoning is unclear, just putting your baby to bed with the pacifier seems to offer protection.

While some breastfeeding advocates have protested giving your baby a pacifier because it is thought to be an obstacle to nursing, Dr. Moon notes that the AAP guidelines specify that pacifiers should not be introduced until breastfeeding is well established, around 4 to 6 weeks. Using a pacifier anytime before age 4 will not ruin your baby's teeth or cause dental problems, and if you wait until breastfeeding is well established, it won't interfere with nursing either. (Keep in mind: Substituting a bottle for a pacifier is not recommended. It can lead to choking, increases dental decay, and may cause ear infections.)

In the United States, 20 percent of SIDS deaths occur while a baby is being cared for by someone other than a parent. "If you work outside the home and leave your baby in the care of anyone else, you must insist that the baby be put to sleep on her back," says Dr. Moon. It can be hard to convince grandparents and other caregivers that back-to-sleep is safer, she adds, "but we've found that if parents give them all the information about the risks, they will comply." Another powerful statistic: The risk of SIDS for babies who sleep on their back at home but are then put to sleep in the unfamiliar prone position by a nonparental caregiver increases by as much as 18 times.

Setting Up a Safe Crib

Babies who sleep in cribs (or on adult beds) with soft bedding -- such as pillows, comforters, and loose blankets -- or stuffed animals, are at risk for SIDS and suffocation. "There should be nothing, nothing in a baby's crib," says Dr. Moon. "A firm mattress, covered by a tight, fitted sheet, is what we recommend." If you use a bumper pad -- which is discouraged by the American SIDS Institute -- it should be thin rather than pillowy and well secured to the sides of the crib. Even during winter, reduce the urge to cover your baby in blankets. Wearable fleece sleep "sacks" are a great option for keeping babies warm. If you live in a moderate climate, use a lightweight sleeper; in colder climates, dress baby in a thicker fleece one. And if you've been turning down the heat in your home to keep your heating bills from skyrocketing, here's a gauge for knowing that baby's room is warm enough: Keep it at a temperature that feels comfortable to an adult in a short-sleeved shirt.

Dana Sullivan, a mother of three, lives and writes in Reno, Nevada.

Originally published in American Baby magazine, February 2006.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.