Safe Sleep for Babies

The only thing better than a sleeping baby, is a healthy, safe baby. For some of us, the idea of a safe sleep space for babies is a no-brainer, for others we might not have even contemplated how and where baby is sleeping. The harsh and frightening reality is though, that some babies die unexpectedly and without an obvious cause, and in most of these cases, it happens quietly while they are sleeping. So a safe sleep space is essential, so read on to find out more.

Sudden Unexplained Death of an Infant (SUDI) is a horrible term used when a baby less than 12 months old dies suddenly and unexpectedly. SIDS (Sudden Infant Death Syndrome) is used when this happens during sleep. While rare (the incidence is around 0.4 in every 1000 births), education and awareness have proven crucial in minimising the occurrence of SIDS, which suggests that an unsafe sleep safe is implicit in many SIDS cases. The preventable death of any baby is one of life's worst tragedies, so here's my contribution to the education and awareness bit.

What is a safe sleep space?

A safe sleep space means that all potential dangers have been removed and the baby's sleep environment is safe. In a very quick summary, the ideal place for a baby to sleep is in a safe cot, on a safe mattress, with safe bedding in a safe sleeping place, for all naps and sleeps. The following safe sleep images come directly from the Red Nose (SIDS awaresness/education/research) website. Here is a visual guide on how your baby's sleep space should look:

Essentially, only items necessary for sleep should be in the sleep space: mattress, cot and baby! No bumpers, pillows, toys etc - these all present suffocation and entanglement risks if babies move about in their sleep (which trust me - they do). There are Australian standards and guidelines for cots and mattresses - you should ensure what you are using complies. If the mattress is too thick or soft, for example, again the risk is that baby's airway may be obstructed in certain positions.

Bub should sleep on his or her back (until they can roll independently, then let them choose), this allows for the most stable position of their airways whilst asleep, and reduces the chance of something blocking their mouth and nose. Their feet should touch the bottom of the cot (to minimise the chance that they wriggle down under something), and if you are using blankets, be sure to tuck them in tightly. Although, as a midwife and a mum, I know how much babies move, and my preference is absolutely that you use a sleeping bag or suit with a known tog (thermal) rating. 

This might all be new to you, or it might sound obvious, but you would absolutely be shocked how frequently I see unsafe sleep practices in my work as a midwife. Admittedly, as a mum I haven't always perfectly adhered to the recommendations either, but it was always an informed decision, with close observation of my bub. I've seen many instances that were downright dangerous and an accident waiting to happen. Don't become a statistic! See the images below for maximum cuteness, but they don't comply with the recommendations (so you see how easy it is to not get it perfect!).

Breastfeeding is known to reduce the SIDS risk (hence it is a recommendation above), whilst a huge amount of SIDS cases involve smoke exposure, which is why it is highly advisable to avoid smoking in the baby's environment.

This bundle of cuteness has a loose blanket, and has some surrounding pillows and bedding which all pose a suffocation risk

This adorable bub has a teddy friend, which is cute but not recommended. It's also advised not to sleep them with their heads covered, as they regulate their temperature through their head - and with a hat or beanie they may overheat

I'm not too sold on the cuteness factor here, but again the head is covered (not to mention the strangulation risk of the ties around the neck!), but the baby is also not sleeping flat on its back, the blanket is loose, and it does not appear to be in a cot or bassinet (no sides visible). It's also a fake baby, so chill, Helen

FAQ and the midwife's tips for baby sleep!

That safe sleep space looks very sterile and unappealing. How can I make it cosy and sleep-inducing for my bub?

Great question. I highly recommend reading up on the "fourth trimester",basically you should aim to mimic the in-utero environment to make a familiar set-up for your babe. This means a tight swaddle (to mimic the boundaries of the womb where they were squished up and contained by you), cuddle them lots (so they can hear your heartbeat and continue being held and warmed by you) and use a white noise machine for sleeping (imitates the background whooshing noises in-utero). You can find out more about the fourth trimester here.

Does anything contribute to increased risk of SIDS?

Yes - smoking, alcohol and drug use are some of the biggest risk factors implicated in SIDS cases. Not sharing the same room as your bub for the first 6-12 months can triple the risk. Not being placed on their back to sleep, or sleeping in unsafe areas such as beanbags, car seats, couches etc (yes - they can look cosy, but they run the risk of rolling/suffocating/head falling forward and cutting off their airway...). Overheating, young babies (under 14 weeks) and bed-sharing have been implicated in SIDS cases. Being a 'vulnerable' infant also is associated with more risk of SIDS - this can include sick, small or premature babies for example.

Does anything decrease the risk (in addition to a safe sleep space)?

Room sharing (but not bed sharing) is protective against SIDS. If possible, you should share a room with your baby for the first 6-12 months. If you are sleep-deprived, try to avoid any activity where you might fall asleep and put the baby at risk (for example, holding baby whilst resting on the couch). Breastfeeding and use of dummies has also been shown to decrease the risk of SIDS.

What about co-sleeping?

Co-sleeping​ gets a bit of a bad rap, because of SIDS. Because the research says the safest way to sleep baby is to share a room but not a bed, co-sleeping is automatically lumped in as a risk factor and dangerous practice. The thing is, it's bloody lovely to snuggle your baby, they love it too, and they'll usually sleep better knowing you're nearby. And in the wee hours of the night, we all choose the option that gives us maximum sleep. I'll let you in on a big secret - many more mums are co-sleeping than let on - because we are scared to admit to this risky (read: not very risky when done right!) practice. If you're going to co-sleep, first of all do your research so it's an informed decision. I couldn't bring myself to do it for months, purely because of my professional knowledge - but once Emilia was bigger, I did it occasionally. Just set yourself up as safe as possible - don't have pillows and bedding that could cover your baby. Use a specific co-sleeper so your baby still has a separate environment (where it's unlikely they'll roll out of a bed or be rolled on by an adult. I strongly discourage any smokers from co-sleeping, and likewise don't do it if you have consumed alcohol recently, are really tired, or have taken medicines which make you drowsy. Likewise, if you have certain medical conditions (obesity, sleep apneoa etc), or bubs is premature, really young or really small, or has a medical condition, I'd be hesitant to co-sleep.

That said, there are some absolutely wonderful benefits of co-sleeping, including more sleep and less sleep problems, which you can read more about here.

How do I know how much to dress them in?

This one can be tricky - think about your ideal sleeping conditions - some of us layer up with cosy PJs, doonas and blankets, others sleep with barely any layers. But with babies, if they are too cold it will interrupt their sleep, but when overheated they don't always wake up, hence overheating is associated with SIDS. The perfect solution here is to monitor the room environment, and use a safe baby sleeping bag with a tog rating based on your room temperatures. This means baby is perfectly dressed for bed, everytime. Studies have shown that other benefits of using safe sleeping bags include reducing the risk of bedding (blankets etc) covering baby's face, they can delay the baby rolling onto its tummy until bub is past the age of greatest SIDS risk, they promote back sleeping (as the zipper is along the front) and they assist baby to maintain a constant, safe temperature whilst sleeping. The other benefit is sleeping bags are easy to zip bub into, learning how to do a perfectly tight traditional swaddle can be a difficult skill to master! If your bub appears to enjoy sleeping arms up, then I highly recommend the Love to Dream swaddles; if bubs enjoys the hands to heart position (or a traditional swaddle), then ErgoPouch would be my recommendation. Both products have guides on the tog rating and room temperature to help you. They are also hip-friendly (baby's legs should never be tightly wrapped or contained to promote healthy hip development). Just hold off buying (if youcan!) until you know which arm position your bub prefers. Bonus points are also awarded to sleeping bags, because they then become a positive, gentle sleep association: your bub will gradually learn that being put in the sleeping bag is one of the signals that it's time to sleep.

Love to Dream arms up

ErgoPouch/Cocoon arms in at chest

Traditional tight swaddle

Surely I can just use a baby monitor with a video and breathing sensors?

I have several issues with these types of monitors. Firstly, there's not a huge amount of knowledge about the exposure to these types of devices, which is concerning given some of them are worn, or placed right underneath the baby. You wouldn't sleep your baby right next to your mobile phone, why would you sleep them right next to, or wearing one of these devices? Secondly, no research has proven that these devices prevent/protect from SIDS. Any monitor that claims this is not to be trusted. Thirdly, I can't help but think these devices give us a false sense of security - that we think an alarm will go off if we need to check on baby, rather than setting up a safe sleep space, and periodically checking your bub/the sleep space yourself to make sure all is well. If you need a monitor, I recommend an audio-only, which will ensure when bub needs you, you'll hear them, but other than that you are relying on visual checks and safe sleep practices.

What about when I wear the baby in a sling or carrier and they sleep there?

Another great question - a frightening case in Australia recently involved the death of a three-week-old baby being worn in a sling. His mum assumed he was sleeping. I can't imagine the horror. 

Slings are fantastic for comforting and hands-free (!), but they do come with safely instructions. Firstly, your baby's airway needs to be clear. You can ensure this is the case if you can see the baby's face at all times. The baby's back should be supported, rather than being curled or cocooned, and they should be in a position that keeps their chin off their chest. A saying worth remembering here is "visible and kissable" - have them in view, and close enough to kiss at all times. If neither of these, then bub is incorrectly positioned in the sling.

What about comforters, toys, pillows, cot bumpers - these all have a purpose, right? When can I use them?

If it were me, I just wouldn't. Yes, they all look super cute at the baby store, but they all present a hazard in one way or another. And before you think I'm a little strict here, we only know about the hazards because they've been implicated in baby deaths before. Comforters are useful, but your baby will be many, many months old before they can have an association between a particular comforter and sleep. At that developmental age, they are at a very low risk of SIDS. Toys - why would you want to stimulate your baby in the place where he/she sleeps? Get rid of toys, mobiles etc. Pillows - absolutely not. They can make the baby roll, cover the head/airways, or become squashed up against the baby as bub rolls around. No, they don't prevent flat spots on the head (that's another issue). Your baby doesn't need a pillow. Cot bumpers are one of my most despised items (I'm sorry!). The cot bars are there for a reason - and no one can argue that fabric is more breathable than that space itself. The ties on cot bumpers are also a hazard (as is any long thing that could entangle the baby), and if they untie then they are a strangulation risk, or the bumpers may fall on the baby itself and present a suffocation risk.

I know it seems like I'm being super extreme here, but please understand that in health care, we really have seen it all. I've seen and heard some shocking stories and cases, and it makes me look at everything from a perspective of "what danger could this pose"? It's the same reason I would never leave a baby on a bed (or another surface) - we've had babies fall off beds in hospital after parents assumed they couldn't roll, being only hours or days old. Just don't take the risk!

I really hope I've covered as much as you need to know here, but please drop any more questions below, and I'll make sure to include them. As with anything, awareness and education is paramount, so be sure to share this article with any friends or family members expecting a baby or with a new bub.

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