Is Your Baby's Cot Safe?

Deciding on a cot for your baby’s nursery may seem as simple as finding something you like that matches your nursery and fits comfortably in the available space. After all, your baby will not be moving much especially during the first few months so surely there are no significant safety concerns. However, the risk of SIDS is highest especially during the first 6 months of your baby’s life. Through years of research certain factors linked to your infant’s sleeping environment which may increase the risk of SIDS have been identified. As a result of this, the American Academy of Paediatrics and the Lullaby Trust have encouraged specific safety guidelines with regards to safe sleep practices.    

Ensuring that your baby’s sleeping environment is safe and secure is vital as they will be spending a significant amount of time there during the first few months of their life. In order to put this into practice, factors such as the safety standards and correct assembly of the cot, the safest place to position the cot and what is safe to have in the cot should be considered.    

There is an overflow of information and advice on the internet and in books about choosing the perfect cot for your baby which can become overwhelming to a new parent. Added to this is the excellent marketing strategies used by manufacturers which lead you to believe that their item is a must have as it will help your baby sleep and is safe to use. However, it is important to keep in mind that your primary goal is to create a safe sleeping environment for your infant. 

Does your cot meet the recommended safety standards?

Most first world countries and continents such as the USA and Europe have established their own safety standards and require all equipment sold there to meet these stringent regulations. Unfortunately, the same cannot be said for South-Africa as there are no specific safety regulations monitoring the quality of infant equipment.    

International safety standards which have been developed by a panel of experts test the following aspects of cots:

General Requirements:

• No hazardous sharp points or edges 
• No small part choking hazards 
• Any paint or surface coating must adhere to relevant standards 
• Be resistant to collapse 
• No scissoring, shearing or pinching hazards
  

• Structural integrity  
• Stability 
• Fabric
  

• Warning label permanency requirements 
• Instruction requirements. 

Should the cot being assessed meet these conditions, it will be issued with a specific code/number which can be published on the product to indicate to consumers that it has been thoroughly tested and is deemed safe for use. South-Africa tends to follow European safety regulations as noted with car seats. The European Standard for a cot is EN 716-1:2008.

If your cot has not been independently tested, what can you look out for?

While international safety standards are difficult for a parent to assess on their own (should the cot not have a safety rating label attached to it) there are other aspects you can look at to  check the safety of  your cot.  Make sure that:

• There are no missing, loose, broken or incorrectly installed screws, brackets or other hardware on the cot. 
• There should be no more than 6cm between crib slats to ensure that a baby’s head or body cannot fit through the slats.  
• No slats are cracked or missing. 
• The corner posts are not higher than 2mm to prevent a baby’s clothing getting caught. 
• There are no decorative cut outs in the headboard or footboard to ensure that a baby’s head does not get trapped or which could be used for a toddler to climb out. 
• The top rail of the cot should be at least 66cm above the top of the mattress support (this is the solid wooden piece which can be moved up and down to adjust the height of the mattress). This is measured when the mattress support is at its lowest. 
• If the cot has a drop gate (not to be confused with a drop side which is illegal) then the cot side must be at least 22.8cm above the mattress support when the gate is in the open or lowered position. 
• The paint should not be cracked or peeling and lead paint which was used before 1978 must be avoided as it is toxic. 
• The  cot must be smooth and not have any splinters or rough edges.  
  

Is your cot set up correctly?

What things are safe to have in your cot?

So often your baby’s cot and specifically bedding is the perfect place to accentuate the theme you have chosen for the nursery. Unfortunately, as beautiful as they may look, they have shown to increase your baby’s risk of SIDS, suffocation and choking. The AAP and the Lullaby Trust firmly advise that the safest way for your infant to sleep is on their back on a firm and flat mattress with no loose items in their cot. By adopting these principals, the incidence of SIDS has decreased over the years. 

The only items that should be in your baby’s cot are:

A firm mattress that fits the cot snuggly

• There should be no more than a 2cm gap between the mattress and the sides of the cot. 
• The mattress must not be elevated in any way.  
• To ensure your baby’s mattress is firm enough, push your flat hand into it. A mattress which bounces back to its original state is firm enough.  
• It is recommended that you purchase a new mattress for each child and not make use of second hand mattresses as they lose their firmness over the years (even if not in use).  
• It must not be made from memory foam as this is a suffocation risk

• Neither should be too tight or too loose as a cover or sheet which is too tight can bend the mattress and one that is too loose can easily come off. Both of these can increase the risk of SIDS and suffocation.   

What items should not be in your cot?

The risk of SIDS is highest during the first 6 months of your baby’s life but still exists up to 12 months. Certain items that you may place in their cot can increase this risk. These items include:

Cot bumpers

Research about bumpers indicate that they do not prevent any serious injuries but rather increase the risk of suffocation and SIDS.  

• Your baby’s face may get pressed against the bumper obstructing their airflow. 
• Often they are still too small and not yet strong enough to move themselves into a safer position. 
• The ties used on cot bumpers leave the possibility of your baby becoming entangled in them or potentially being strangled.  
• This is supported by the AAP as they state that cot bumpers should not be used as the risks outweigh any benefits.    

Duvets and blankets 

Blankets and duvet’s can easily fall on top of your baby’s face while they sleep. This could be a potential suffocation or choking hazard as they do not yet have the co-ordination to move it out the way. Babies are also not yet able to regulate their own body temperature. By placing a blanket or duvet over them you increase the possibility of overheating as they would not be able to take it off should they feel hot. 

There is no specific age which indicates when a blanket can be introduced. However the AAP advises that it should not happen during the first year of life. Ideally the later you introduce it the better. 

When introducing a blanket, there are still ways to make it less of a safety risk. Choose a blanket that:

• Is smaller rather than larger 
• Thin such as a cellulose or muslin blanket 
• Does not have any edging such as ribbons or ties   

Pillows 

Pillows can increase your baby’s chance of suffocation as their heavy head can sink into the pillow leading to their mouth and nose becoming covered. A pillow also places unnecessary strain on your baby’s neck. 

As with blankets and duvets, it is recommended that pillows not be introduced before 12 months of age (preferably 2-3 years). The best time to introduce a pillow is when your infant moves into a toddler bed. Ensure that the pillow you choose is smaller and firmer than a standard adult pillow.    

Stuffed toys 

Stuffed toys fall in the hazardous group of items in your baby’s bed. The only exception is when introducing a comforter or soother to your baby.  Even so, this should not happen before your baby is older than 3 months. 

Your baby will begin to make associations around 6-7 months which is the best time to introduce a comforter or soother.  A suitable soother is one which is lightweight and does not have any small or detachable parts which can pose a choking risk.   

Wedges, baby nests/pods, or any sleep positioners

Wedges, baby nests/pods, or inclined positioners are often marketed as devices which keep your newborn safe by preventing them from rolling over or decreasing reflux.  However, they have been the cause of numerous infant deaths due to the baby’s face being pushed against the side of the positioner or because the baby rolled and got stuck between the sleep positioner and the side of the crib.  

Your baby may not be able to get out of this unsafe position which could lead to breathing difficulties and suffocation.  This also applies to any home-made positioners such as nursing cushions or rolled up blankets. 

Where should your cot be positioned?

The safest place for your baby to sleep especially for the first 6 months when the risk of SIDS is the highest is in the same room as you. This is known as room-sharing which means that your infant sleeps on a surface which is firm and flat and free of any loose items and is most importantly separate from you. This has shown to decrease the risk of SIDS by up to 50% due to the fact that your baby is within your view which makes it easier to monitor them, respond to them quicker if you identify any dangers as well as comfort and feed them.    

The AAP has flagged bed-sharing as a considerable risk for SIDS as it significantly increases the chance of suffocation, strangulation, entrapment and overheating. Cases which have been reported indicate that this occurred as a result of a parent accidentally throwing a blanket or duvet over the infant, rolling on top of them, or their face being accidentally pushed into a pillow.    

Once your baby moves into their own room, it is recommended that their cot be placed right up against a wall with no gaps or at least 30cm away from the wall. This makes sure that should your baby begin to climb out their cot, the chance of them becoming trapped between the wall and the side of the cot is reduced.    

There are other important considerations which should be taken into account when placing your baby’s cot in the nursery. Any objects which could potentially cause harm should be avoided. This includes: 

• Placing their cot under or close to a window that has curtains or blinds. Curtains and blinds are potential strangulation and suffocation risks. There is also the risk that your child may try to climb out of their cot and become trapped between the burglar bars. 
• Under or near a window and close to a heater (wall or freestanding). A baby is not yet able to regulate their own temperature and exposing them to direct sunlight or being too close to a heater can cause overheating which is a significant SIDS risk. 
• Placing the cot close to or against a plug point. 
• Placing hanging mirrors, shelves or artwork above the cot as these items could fall onto and injure your baby and the shelf itself could become loose. 
• Placing decorations near or around the cot which have ribbons or loose strands. This is especially important with cot mobiles as they should not be within the reach of your baby. 
• Attaching dummies or any other objects with a string to the side of the cot.  
• Placing cameras on the side of the cot or attached to the wall the cot is up against. This makes it easier for them to grab the power cable which could cause the camera to fall on top of them as well as it being a strangulation risk. 
• Placing the cot too close to other furniture such as a compactum, changing table or nursing chair as these can be used to help them climb out of their cot.
  

How should your baby be positioned in their cot?

The AAP and the Lullaby Trust suggest specific sleep recommendations to reduce the risk of SIDS for your baby. These recommendations which have significant evidence supporting them were updated in 2022.  

They strongly advise that the following are put in place for every nap and overnight sleep for the first 12 months of your baby’s life: 

• Ensuring they sleep on a flat and firm surface with a waterproof covering 
• Placing them to sleep on their back 
• Keep their cot empty with no blankets, pillows or soft toys 
• Sharing a room (not a bed)

Should your baby’s sleep position change as they get older?

Newborn: 

• The safest position at this age for your baby is to sleep flat on their back on a firm and flat mattress with no loose items in their cot. 
• Swaddling your baby with their hands together near their face is recommended for the first two months as it is comforting for them. 

• Sleeping on their back is still the safest. 
• They may start to push up on their arms and lift their head when lying on their tummy, however it is still not safe to put them to sleep in this position. 
• Moving your baby from a swaddle to a sleep sack is recommended at this time. 

• Although your baby is now able to roll over on their own it is still safest to place them on their back. 
• If your baby were to roll onto their side or tummy on their own, there is no need to move them as they have more strength and co-ordination to get back to a safe position.  
• It is important that their cot be lowered at this time to prevent them from falling out. 

• Even though your baby is far more mobile, putting them to sleep on their back is still the safest. 
• They will likely move into various other positions while sleeping which is completely safe as long as there are no loose items around them.
• When your baby is able to start pulling themselves up, it is time to lower the cot again. 

What concerns do parents usually have?

Vomiting and choking: 

One of the first concerns that parents have when hearing that putting their baby down on their back to sleep is the safest, is won’t my baby choke if they vomit?  While it is a valid concern, the National Institute of Health along with all other medical practitioners reveal that the opposite is in fact true.  

Your baby has an automatic reflex which makes them cough or swallow anything that comes up.  Lying on their backs make it easier for them to do this therefore making it a safer position.  

A baby who vomits while lying on their side or tummy will not be able to ingest whatever has come up. This means that they would likely  inhale or choke on their vomit which may be fatal.  

Reflux: 

Contrary to popular belief, “elevating the head of the infant’s crib is not effective in reducing reflux”.  It will also not prevent them from choking if they vomit as indicated in the previous point. 

Raising the head of your baby’s cot or using something to place them at an incline increases the risk of them sliding to the bottom of their bed and potentially into a position which could cover their mouth and nose.  

In conclusion

Digesting and trying to make sure you remember all of this information is overwhelming. However, the most important principles to take into consideration are making sure your baby is placed on their back on a firm and flat surface to sleep on with no loose items around them. 

references

https://pediatrics.aappublications.org/content/138/5/e20162938 

https://www.mattressnut.com/assemble-cot-bed/ 

https://www.ncbi.nlm.nih.gov/books/NBK513389/

https://www.childrenshospital.org/conditions-and-treatments/conditions/s/sudden-infant-death-syndrome-sids/symptoms-and-causes 

https://www.lullabytrust.org.uk/safer-sleep-advice/sleeping-position/ 

https://safetosleep.nichd.nih.gov/safesleepbasics/SIDS/fastfacts 

https://safetosleep.nichd.nih.gov/safesleepbasics/tummytime 

https://www.nichd.nih.gov/sites/default/files/2019-02/Safe_Sleep_Environ_update.pdf 

https://www.healthline.com/health/baby-sleeping-on-side#The-most-serious-risk:-SIDS 

https://www.medicalnewstoday.com/articles/baby-sleeping-on-side#changing-positions 

https://www.astm.org/COMMIT/SUBCOMMIT/F1518.htm 

https://www.cpsc.gov/Regulations-Laws--Standards/Rulemaking/Final-and-Proposed-Rules/Full-Size-Cribs 

https://www.cpsc.gov/Business--Manufacturing/Business-Education/Business-Guidance/Full-Size-Baby-Cribs

https://www.childsafetyeurope.org/publications/info/product-safety-guide.pdf 

https://www.sgs.com/en/news/2018/03/safeguards-03618-publication-of-a-european-standard-on-mattresses-for-cots-and-cribs 

https://www.cen.eu/WORK/Pages/default.aspx 

https://raisingchildren.net.au/newborns/safety/equipment-furniture/safe-baby-furniture 

https://www.encorebabyregistry.com/safety-considerations-for-secondhand-cribs/ 

https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx 

https://onsafety.cpsc.gov/blog/2011/06/14/the-new-crib-standard-questions-and-answers/ 

https://www.tuvsud.com/en/e-ssentials-newsletter/consumer-products-and-retail-essentials/e-ssentials-3-2019/usa-astm-publishes-new-infant-bathers-standard-astm-f3343-19 

https://www.verywellfamily.com/baby-bedding-avoiding-the-dangers-284446 

https://us.bsensible.com/blogs/news/what-to-consider-when-shopping-for-your-baby-s-crib-sheets 

https://us.bsensible.com/blogs/news/which-type-of-crib-sheet-is-best-for-your-newborn 

https://www.babysleepsite.com/safety/what-age-can-my-baby-sleep-with-a-stuffed-animal/ 

https://www.healthline.com/health/baby/when-can-baby-sleep-with-blanket#takeaway 

https://www.healthline.com/health/parenting/crib-bumper-safety#Are-breathable-bumpers-better?- 

https://www.bestproducts.com/parenting/baby/g2972/safe-baby-crib-bumper-mesh-liners/ 

https://www.thehealthsite.com/parenting/5-reasons-your-infant-doesnt-need-a-pillow-251521/ 

https://www.which.co.uk/reviews/cot-mattresses/article/baby-bedding-safety-adNyB4h5WC89 - Which? 

https://www.lullabytrust.org.uk/safer-sleep-advice/mattresses-and-bedding/ 

https://www.which.co.uk/reviews/cot-mattresses/article/cot-mattress-safety-at19Y2M0qDEd 

https://www.which.co.uk/news/2020/01/why-are-so-many-cot-mattresses-failing-safety-tests/

https://www.which.co.uk/news/2019/07/how-often-should-you-clean-your-babys-cot-mattress/ 

https://rednose.org.au/article/what-is-a-safe-mattress 

https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Make-Babys-Room-Safe.aspx 

https://www.verywellfamily.com/a-guide-to-the-standard-crib-mattress-size-284559 

https://www.sealybaby.com/sleep-time-blog/crib-mattress-fit/ 

https://www.thesleepjudge.com/foam-vs-coil-crib-mattress-what-you-need-to-know/ 

https://rednose.org.au/article/sleeping-position-for-babies-with-gastro-oesophageal-reflux-gor