Nearly two decades ago, the phrase "Back to Sleep" became part of the baby-care lingo for new parents. It was a direct response to a crisis: As many as 6,000 U.S. babies were dying each year of sudden infant death syndrome, or SIDS. Then, research in Europe and Australia showed that putting babies to sleep on their back could reduce SIDS. One reason for the decrease may be because babies retain more body heat when they lie on their belly, so they may sleep more deeply and have trouble waking if their face gets pressed against bedding. Belly- and side-sleeping also increase a baby's risk of rebreathing exhaled carbon dioxide. As a result of the findings, federal child-health agencies in the U.S. initiated the Back to Sleep campaign to educate parents and caregivers. The message got through: Within ten years, back-sleeping rates escalated and SIDS deaths dropped by more than half. "It was one of the greatest public-health-education triumphs of the late-20th century," says neonatologist Michael Goodstein, M.D., a member of the American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome. "An estimated 30,000 children are alive today because of Back to Sleep."
The cause of SIDS remains unknown. It is the diagnosis given when a baby's death can't be explained by a complete autopsy, investigation, and family medical history. And while 70 percent of infants who die of SIDS turn out to have had some type of brain-stem abnormality that affects things like breathing, heart rate, and the ability to awaken, it's not a given that these same babies died because of that abnormality.
As forensic teams are more closely examining the beds, bedrooms, and surfaces where babies have died, a devastating trend has emerged: Many deaths that once looked like SIDS are turning out to be accidents that could have been avoided. Doctors consider SIDS to be only one part of a category of accidental deaths called Sudden Unexpected Infant Death (SUID). The other parts, according to the Centers for Disease Control and Prevention, are accidental suffocation and strangulation in bed, and sleep-related "ill-defined and unspecified" deaths. In 2010, the most recent year for which stats are available, a total of 3,610 U.S. babies under the age of 1 died of SUID. "It's very disheartening," says pediatrician Rachel Moon, M.D., of Children's National Medical Center, and a member of the AAP Task Force. "Most of the time, parents think that they're doing what's best for their baby. But the majority of those who die from SUID had been bedsharing or had a blanket or a pillow while sleeping. They didn't have to die."
That's why, when the AAP reviewed all recent safe-sleep research and updated its recommendations two years ago, it revised guidelines to address both the risk of SIDS and sleep-related deaths. The AAP report recommends feeding babies breast milk and offering pacifiers, both of which have been shown to help reduce the risk of SIDS. Parents should not expose babies to secondhand smoke, which is linked to higher SIDS rates. They should also avoid monitors or other devices marketed as reducing SIDS risk.
But it's how you put your baby to sleep that is most important, notes the AAP. Not only should babies be put to sleep on their back, but they should be placed in a crib without pillows, toys, blankets, or bumpers. Also, never lay a baby down on any soft surface. And because a significant number of deaths occur when parents inadvertently roll over on their baby or accidentally block their baby's mouth or airway, sleeping together is not recommended, whether in a bed or on a couch. A recent analysis of bedsharing studies, conducted by Dr. Moon, among others, found that sleeping with an infant under 3 months of age triples her risk of suffocation death.
Child-safety organizations and doctors are eager to spread the word about the expanded recommendations. The Eunice Kennedy Shriver National Institute of Child Health and Development announced a campaign called "Safe to Sleep" that includes SUID precautions. But many parents don't think of safe-sleep practices as a necessity. In fact, studies suggest that only 75 percent of parents put babies on their back. Many resist because they think their baby is particularly fussy or gassy, or requires special accommodations. In addition, despite ample evidence about the dangers, many parents share their bed with a young infant. Some swear by the ease of nighttime feeding, and the calming effects. Bedsharing is ingrained in countries such as Japan, Sweden, and the Philippines, and thought of as a way of developing family closeness.
"Every parent thinks their child is the exception to the rule," says Dr. Moon, adding that sleep-related accidents always take parents by surprise. "They never think it's going to happen to them." We spoke with several moms who have experienced either close calls or tragic losses. They shared the facts they desperately wish they'd learned sooner.
Michele Hoelzer, of Centereach, New York, and her husband had a son who was born prematurely and died an hour after birth. When their daughter, Josephine, was born at full term five years ago, they felt blessed--and also protective. "I wanted her close to me at every moment," Hoelzer says of her decision to bring her baby into bed at night. After all, she and her husband didn't drink alcohol or take drugs and they were both light sleepers; they'd surely hear it if Josephine was in distress.
But one morning when Josephine was 6 months old, Hoelzer woke and momentarily couldn't find her baby in the bed. She realized that her husband's upper body was covering Josephine's face. She pushed him off the baby, who stirred and gave a reassuring wake-up cry. Today, she's a vibrant kindergartner who loves music and art, but Hoelzer points out that the outcome might have been different if they'd slept even minutes longer.
The AAP recommends that infants sleep in a crib that is close to but separate from the parents' bed. In fact, there is evidence that sharing a room with your baby decreases the risk of SIDS by as much as 50 percent. Hoelzer, a member of the Facebook group Parents Against Unsafe Sleep Environments (PAUSE), continues to warn other parents about the dangers of bedsharing. "It was terrifying," she says. "After that morning, we kept her crib less than 2 feet away from our bed. I didn't care how many times during the night I had to get up."
Three years ago, Elizabeth Matlick, a teacher in Seattle, and her husband, Justin, selected a well-recommended in-home day care for their 10-week-old daughter, Vivian. Elizabeth felt confident in the providers, an older couple, and also thought she'd be insulting them to reiterate the Back to Sleep guidelines. "It seemed like a no-brainer," she says.
On Vivian's fourth day, the caregivers found her during naptime, facedown in the play yard, nearly blue and not breathing. Paramedics put her on a ventilator and rushed her to the hospital. Miraculously, she regained consciousness the next morning, but the lack of oxygen caused her brain to swell and she had a dozen seizures over three days in the NICU. Happily, after a year of precautionary physical therapy to maintain her reflexes, she has hit all of her developmental milestones. The day-care providers insist they had put Vivian on her back, but her parents still are not sure what happened, as they'd never seen her roll over. It's possible, Matlick says, that Vivian was placed not on her back but on her side and managed to wriggle onto her belly.
After giving birth to a second daughter, Anna, Matlick is still shaken by the ordeal. She's now explicit with everyone about putting Anna on her back. "You've got to have the conversation, even if you feel ridiculous," she says.
In fact, parents should discuss safe-sleep habits with everyone, starting with hospital staff. "Tell babysitters, friends, and especially grandparents, who might have done things differently in their time," explains Dr. Goodstein, who's helped initiate safe-sleep education programs for health providers. When it comes to day care, don't wait: Most sleep accidents happen within the first week, Dr. Moon has found.
People assume that babies with reflux shouldn't sleep on their back, but studies have shown that belly-sleeping isn't an effective antidote. It's also a myth that back-sleeping babies will choke on their spit-up. The AAP recommends babies get supervised tummy time. "That helps them gain the neck muscles they need to move their head from an unsafe position," says Dr. Goodstein.
Three years ago, Shannon and Chris Greub, then living in Spearfish, South Dakota, were delighting in their 9-month-old daughter, Aspen. "She was a very happy baby, never sick, and she was ahead in all her milestones," says Greub. She and her husband had set up Aspen's crib with beautiful bedding, including matching bumpers and blanket. "You buy all these pretty things when you're having a baby," she says. "I didn't know they could be dangerous."
In the early hours of an October morning, anticipating Aspen's periodic waking during the night but hearing no noise, Greub rushed to Aspen's room with the sense that something wasn't right. She found her baby had rolled onto her stomach and had somehow pulled the blanket off the back of the crib. Her head and body had gotten tangled in it, and she wasn't breathing. "I screamed," she recalls. "My husband called an ambulance. He tried to do CPR until it arrived," she says. "I felt like my world was crashing down." The paramedics continued CPR and then rushed Aspen to the hospital. "They tried to bring her back, but they couldn't."
Today, the parents are exceedingly careful with bedding for their 21-month-old daughter, Rylee. Greub uses Facebook to spread the word that cribs shouldn't contain blankets, pillows, bumpers, or stuffed toys. She's been stunned to meet hundreds of parents online who've lost babies in similar ways: "You don't realize how common it is until it happens to you."
Liz Montgomery had recently returned from maternity leave to her teaching job in 2003 when she brought 5-month-old Mason to a trusted sitter's house. Montgomery told her it was okay to put Mason to sleep on his back on the couch, which was how he often napped at home, with a blanket over him.
To this day, it's not clear what happened to Mason during his nap. Within 15 minutes of putting him down, the sitter checked on him and found him not breathing. "I don't know if he rolled into the couch cushions or if he overheated," says Montgomery, who has never been able to bring herself to ask what position her son was in. After being airlifted to a major hospital, Mason was put on life support but showed no brain activity. After 24 hours, his family decided to remove life support. Although the medical examiner's report said that Mason had died of SIDS, Montgomery began to research the dangers babies face when they sleep on a soft surface. She does not blame the sitter, who remains a close friend, but now she'll tell everyone she can that the safest environment for a baby is in a crib. And in February 2012 she started the Inland Northwest SIDS Foundation in Idaho to provide education for parents.
The AAP recommends that babies always sleep in a crib, a bassinet, or a play yard with a firm mattress. It's okay if they fall asleep in a car seat while traveling, but Dr. Goodstein recommends they be taken out every one to two hours. Babies should never be put down to sleep in a car seat, though--even for a nap. "If a baby's head tips forward, especially at a young age, it could partially block her airway and make it hard for her to breathe," he explains. And couches, like adult beds, are too soft to be safe.
The AAP notes that breastfeeding up to a year, even if the milk is pumped, can protect against SIDS. But that doesn't mean moms should breastfeed in bed when they're tired, even if being in bed makes nursing easier. Tammy Jones, of Columbus, Missouri, wants parents to know that bedsharing is never safe, even if a health professional suggests it.
Already the mom of a 3-year-old daughter, Jones was a graduate student at the University of Missouri when she gave birth a few weeks early to twin girls, Whitney and Megan. A nurse recommended taking her 7-week-old babies to bed with her to help breastfeed through the night. Jones had been sleeping with her infants beside her when she was awakened one morning by her oldest daughter and realized something was wrong. Next to her in bed, Whitney was still, her face blue. Jones called 911 and performed CPR, trying to stay calm. "By the time the ambulance arrived, she was gone," she says. "My heart wasn't broken. It was shattered."
An autopsy described the death as SIDS, known to be more prevalent in preemies. But as Tammy began to talk with doctors and to read studies about how sleep-related deaths tend to occur, she believed bedsharing played a role. In support groups, speaking engagements, and other advocacy work, she's getting the word out about safe sleep for babies under 1 year old. "I didn't know then that bedsharing was a danger," Jones says. She hopes to spare other parents similar grief: "It's the only way I could find meaning in such a senseless death."
You'd never want to do anything to endanger your baby. Safe-sleep environments, experts urge, are as essential as car seats. "There are no exceptions," says Dr. Moon. "We want every baby to be safe."
All your baby needs is a bare crib with a firm mattress.
1. Crib wedges, which are propped under the top of the mattress, are no longer recommended to help babies with reflux. According to the AAP, studies have not shown that elevating a baby's head is beneficial. What's more, a wedge may cause a baby to slide to the foot of a crib into an unsafe breathing position. "I've seen babies slide and roll down to the bottom of an incubator when it's been elevated," Dr. Michael Goodstein says.
2. Bumpers, even ones that wrap around individual bars and those advertised as being "breathable," all pose a risk if a baby gets his face pressed against them. As a result of infant deaths, bumpers have been banned in Chicago.
3. Baby recliners, which are similar to wedges in that they are intended to position babies relatively upright while sleeping, have been recalled for causing infant deaths when babies slid into an unsafe position. They should never be placed in cribs--babies have been found to have leaned over the side of the recliner and suffocated against a mattress. They should never be placed in beds, either, where parents may roll on top of them.
Editor's Note: In the print version of this story, one sentence read "The AAP report recommends feeding babies breast milk and offering pacifiers, both of which have been shown to help prevent SIDS." We have changed that sentence to reflect the fact that these behaviors only reduce the risk of SIDS--because SIDS cannot be prevented--and we regret the error. Also in the print version, we say that bumpers have been banned in Maryland. But vertical bumpers that wrap tightly around each crib rail or mesh crib liners are excluded from the ban (though Maryland's Department of Health and Mental Hygiene does not recommend the use of these novel products).
Originally published in the November 2013 issue of Parents magazine.
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