What is safe sleep for your baby?

Posted by Megan Petschel, Robyn Hunt & Julie Monson on

what is safe sleep for babies

Almost all new parents have been warned about the potential risks of SIDS. Adding to their concern is the lack of knowledge regarding the cause of SIDS which makes knowing how to prevent it difficult. 

Years of research has been poured into this topic yet no specific answers have been reached. Certain factors which are known to increase the risk of SIDS have been identified and based on these, three main schools of thought about safe sleep have emerged.    

In this article we will be discussing the 3 main schools of thought on Safe Sleep. While there may be differences in opinion between The American Academy of Paediatrics, Lullaby Trust and the International La Leche League, they all agree that the safest position for your baby to sleep is on their back on a firm mattress with no loose items around them. They also share a common thread that safe sleep saves lives.

These safe sleep practices are not only intended to reduce the risk of SIDS but also prevent other sleep-related deaths. There is no right or wrong choice out of the suggested safe sleep practices. It is important to rather empower yourself with knowledge to help make a decision on what works best for your family. 

Safe sleep for baby

What is sids?

The Safe to Sleep Campaign defines Sudden Infant Death Syndrome (SIDS) as an unexpected and unexplained death of a baby under the age of 1 with no known cause after investigation. Sadly, SIDS is the main cause of death in infants between the ages of 1 month and 1 year with the rate peaking during the first 4 months of life. It is reported that over 90% of SIDS deaths occur before a baby reaches 6 months of age.  

what is the current thought behind sids?

The current train of thought as indicated by the Boston Children’s Hospital is that SIDS is linked to difficulties in the ability of a baby to wake up from sleep and detect low levels of oxygen or a build-up of carbon dioxide. 

A baby who sleeps on their tummy may re-breathe carbon dioxide which they have exhaled. This increase in the amount of carbon dioxide should alert their brain to activate the respiratory system and wake the baby up so that they are able to turn their head and breathe faster to get more oxygen. However, babies who pass away from SIDS may not wake-up in order to turn their head and breathe faster. 

Safe sleep for baby

what are the risk factors of sids?

Although SIDS is not entirely preventable, the following risk factors increase the possibility of SIDS: 

  • Babies who sleeps on their tummy or side as opposed to their back  
  • Babies who sleep on a soft surface   
  • Babies who sleep with blankets, soft toys or cot bumpers  
  • Babies who overheat whilst sleeping  
  • Babies who were born prematurely or with a low birth weight  
  • Mothers who smoked during the pregnancy (a SIDS related death is 3 times more likely to occur)  
  • Mothers who were exposed to secondary smoke from other members in the same house  
  • Mothers who had little or no prenatal care during their pregnancy  
  • Babies who have a sibling pass away from SIDS  
  • Babies who sleep in the same bed as their parents 
  • Babies who sleep in a car seat, couch or baby swing etc.

pillows, blankets, cot bumpers not safe for babies

what should sids not be confused with?

As important as knowing what SIDS is, the Safe to Sleep Campaign also indicates specific things that SIDS is not. SIDS should not be confused with the following: 

  • SIDS is not the same as suffocation and is not caused by suffocation.  
  • SIDS is not sleep apnoea  
  • SIDS is not caused by vaccines or immunizations  
  • SIDS is not contagious.  
  • SIDS is not the result of neglect or child abuse.  
  • SIDS is not caused by cots.  
  • SIDS is not caused by vomiting or choking

what other sleep-related causes of death are there?

Sudden Unexpected Infant Death Syndrome (SUIDS) is the term used to group all sudden and unexpected deaths during the first 12 months. SUIDS takes into account both deaths where the cause is unknown (such as SIDS) as well as those in which the cause is evident. 

Although SIDS accounts for the majority of infant deaths, other sleep-related infant injuries or deaths occur as a result of how and where your baby sleeps. 

The Safe to Sleep Campaign mentions 3 types of possible injuries or mechanisms of death which fall under the SUIDS category and not SIDS: 

  • Suffocation can happen when the baby's airway becomes obstructed or blocked and they are unable to get sufficient oxygen. This can result from soft bedding such as mattresses which are not firm enough, blankets, duvets, pillows or cot bumpers being placed in the baby’s sleep environment. 
  • It can also result from “overlaying” or smothering, which is when another person sharing the same sleeping surface as the baby rolls on top of or lays against the baby restricting their breathing.   
  • Entrapment happens when a baby becomes trapped between two items such as a mattress and the side of the cot, wall or furniture. This can result in them getting stuck in a position in which their airway is compromised and they cannot breathe.
  • Strangulation occurs when something presses on or gets wrapped around a baby’s head and neck and closes off their airway, such as a blanket, mosquito net, dummy strap or teething necklace.

In order to minimise the chance of SIDS and other sleep-related deaths from occurring, safe sleep practices were introduced. Since these practices were established, the number of SIDS deaths has dropped dramatically. 

suffocation, strangulation, and entrapment cause of SIDS

what are the abc's of safe sleep?

In 1994, the American Association of Paediatrics (AAP) introduced the Safe to Sleep Campaign to assist in decreasing the number of babies lost to SIDS. While their main slogan was “Back to Sleep” and encouraged parent’s to place their babies on their backs when sleeping, it was later expanded to the ABC’s of safe sleep. 

Your baby should always be 

Alone, on their Back and in their Cot.

A is for alone

The AAP encourages sharing a room with your baby especially for the first 6 months, however, they discourage sharing a bed. Placing your baby to sleep on a separate surface such as a co-sleeper or Moses basket next to your bed is the safest place for them. The strongly advise against falling asleep with your baby if you are on a couch or chair. 

B is for back

The practice of placing your baby on their back for every nap and sleep has proven to reduce the risk of SIDS significantly. The first thing that parent’s worry about when they hear this is the safest position for their baby to sleep is “won’t they choke if they vomit?” 

Babies have an automatic reflex which allows them to cough or swallow anything that comes up which helps them clear any vomit. If they were to vomit while on their stomach, there is a far greater chance that they would inhale or suffocate as they may not be able to move their heads to open their airway.  

baby's airway on back vs front

c is for cot

In line with sleeping alone, your baby should sleep in their own cot with a mattress that is firm and flat as this helps reduce the chance of suffocation. Ensuring that your baby’s cot is safe also involves ensuring that there are no loose items such as duvets, blankets, pillows, stuffed animals or bumpers as they also increase the risk of suffocation should your baby accidentally roll into them. 

The safest cot for your baby is one that is empty, with only a firm fitted mattress and waterproof fitted sheet. This includes not using any type of sleep positioners or wedges as they pose a large danger should your baby roll around while in one.   

Safe sleep list ABCs

what are the safe 7?

The International La Leche League, who specialise in lactation, indicates that although most breastfeeding moms do not plan on sharing their bed with their baby, ultimately 60-75% will at some stage do so. 

While they acknowledge that this is not in line with most safe sleep practices, they also recognise the benefits that are associated with sharing a bed. Those who do so report that they get more sleep and experience positive benefits on their milk supply.  

The International La Leche League indicates that bedsharing is safer when you are breastfeeding because your body will automatically move into a cuddle curl position. 

In this position, your knees are bent and your arm is under the pillow to provide a cocoon-like environment protecting your baby. They do note that a mom who does not breastfeed loses some of this protection when sharing a bed with her infant. This coincides with evidence that points out that breastfeeding reduces  the risk of SIDS.  

To make this practice as safe as possible, they developed the Safe 7:

  1. You should be a non-smoker. 
  2. You should be sober and unimpaired by any type of medication or drugs. 
  3. You should be breastfeeding. 
  4. Your baby should be healthy and full-term. 
  5. Your baby should be on their back.  
  6. Your baby should be lightly dressed. 
  7. Both of you should be on a safe surface.
la leche league safe 7

With regards to point 7 above, the International La Leche League put a checklist into place to help you make sure the surface you share is safe:

  • Avoid these items as they can be a potential smothering risk:
    • Couches, chairs or recliners. ·         
    • A soft or sagging mattress that could cause your baby to roll into you or prevent them from lifting their head to be able to breathe.
    • Avoid spaces where your baby may get stuck such as spaces between mattresses, headboards and walls.         
    • Pets which sleep on the bed.
  • Make sure your bed does not have any:
    • Unused pillows 
    • Heavy blankets or duvets         
    • Stuffed toys         
    • Any items such as cords or strings nearby
  • Check your bed for potential hazards:
    • The distance from the bed to the floor.   
    • The landing surface i.e. carpet or tiles or side tables. 
    •  Anything that is sharp or could poke or pinch.

The International La Leche League claims that should you meet these 7 criteria your baby is at no greater risk of SIDS than if they were sleeping in a nearby  cot. At the time of publishing, we could not find statistics to verify this claim. 

By the time your baby is four months old, studies show that bedsharing with a “healthy baby by any responsible non-smoking adult on a safe surface is as safe as any other sleep arrangement.” 


The Lullaby Trust's advice is based on strong scientific evidence. They recommend that Safe Sleep advice be followed for every nap, including during the day, 

You should always place your baby on their back to sleep and not on their front or side. There is substantial evidence from around the world to show that sleeping your baby on their back at the beginning of every sleep or nap (day and night) significantly reduces the risk of sudden infant death syndrome (SIDS). 

Place your baby to sleep in a separate cot or Moses basket in the same room as you for the first 6 months, even during the day. A large study of evidence from across Europe found that the risk of sudden infant death was significantly reduced when the infant slept in the same room, but not the same bed, as the parents.

The safest mattresses for your baby are firm and flat and protected by a waterproof cover.

Babies are at higher risk of SIDS and accidental suffocation if they have their heads covered, so it is safest to keep baby’s cot clear of any items such as bumpers, toys and loose bedding bedsharing/ co-sleeping

which method is safest?

The AAP strongly discourages how to sleep safely whilst breastfeeding. while the La Leche League and Lullaby Trust believe it is safer to do so if their respective recommendations are adhered to. However, they all agree that babies are safest being put to sleep on their backs, on a firm and flat mattress with no loose items around them. 

It is important to note that co-sleeping while breastfeeding does pose a risk of your baby being smothered against your body, if you were to fall asleep. Read our article on how to sleep safely whilst breastfeeding.

safe sleep for baby

It is not within our scope as Occupational Therapists to determine which method is safest. No matter how you and your baby choose to sleep, being informed of the benefits and risks of both methods and aware of how to make it as safe as possible, empowers you to make the safest decisions for your baby. This goes a long way in reducing the risk of SIDS or any other sleep-related injuries or death. 


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