Safe Sleeping and Babies

Things you should know:

• Sleep baby on the back from birth, not on the side or tummy.
• Sleep baby with head and face uncovered.
• Keep baby smoke free before birth and after birth.
• Provide a safe sleeping environment night and day.
• Sleep baby in their own safe sleeping place in the same room as an adult caregiver for the first six to twelve months.
• Breastfeed baby.

Why safe sleeping is important

• All parents want the best for their baby. Most parents know that some infants die unexpectedly in their sleep and are keen to know how to reduce the risk.
• Since safe sleeping recommendations were introduced in the early 1990’s the incidence of Sudden Unexpected Death in Infancy (SUDI) has decreased by over 85% with an estimated 10,000 babies lives being saved.
• Since safe sleeping recommendations were introduced in the early 1990’s the incidence of SUDI has decreased by over 80% with over 12,069 babies lives being saved. In 2022 there were 117 SUDI deaths across Australia.

Sleep baby on the back from birth, not on the tummy or side

There is now conclusive evidence from many countries that sleeping infants on their tummy (prone sleeping) significantly increases the risk of SUDI.

• Some parents are concerned about sleeping babies on their backs because they believe there is an increased risk of their baby choking in this position. However, careful study of the baby airway has shown that healthy babies placed to sleep on the back are in fact less likely to choke on vomit than when sleeping on their tummy. This is because when babies sleep on their backs the upper respiratory airway is above the oesophagus (digestive tract) therefore, regurgitated milk ascending the oesophagus is readily swallowed again so aspiration into the respiratory tract is avoided. When the baby is placed on their tummy the oesophagus sits above the upper airway so if the baby regurgitates or vomits milk, it is relatively easy for the milk or fluid to be inhaled into the airway and lungs, leading to aspiration, choking or reduced breathing.
• Parents often say that their baby “sleeps better” on their tummy. This is because babies have more deep sleep in this position so they arouse from sleep less frequently. A failure to arouse from sleep is widely believed to be the reason why babies die from SIDS. When babies sleep on their tummies they have lower blood pressure and lower oxygen levels in their brain and this will contribute to their reduced ability to arouse from sleep.
• Babies born prematurely are often slept on their tummies while being monitored in the neonatal nursery and this is to improve their breathing stability. However, it is important that babies who have been born prematurely are slept on their backs at home, as they are at increased risk for SUDI, and there is no evidence that sleeping on the back has any deleterious effect on them.

Sleep baby with head and face uncovered

There is now conclusive evidence from many countries that covering of a baby’s head or face significantly increases the risk of SUDI.

• Parents are currently advised to place the infant at the foot of the cot in the “feet to foot” position and to make the bedding up with a sheet and blanket so that there is a reduced risk of the infant slipping under the bedding.
• Heavy bedding, such as doonas, duvets and quilts should never be used. Anything that could cover a baby’s face should not be in the cot, this includes pillows, security blankets and toys.
• Cot bumper pads and similar products that attach to the sides of the cot are also not recommended because of the danger of entrapment between the mattress and the bumper pad and the risk of strangulation with bumper pad ties.
• A safe infant sleeping bag provides a good alternative to traditional bedding. A safe infant sleeping bag is one that is made in such a way that the infant cannot slip inside the bag and the head become covered. The infant sleeping bag should be the correct size for the infant, with a fitted neck and armholes or sleeves to keep the baby warm and no hood to avoid any chance of head covering.

Keep baby smoke free before birth and after birth

There is now conclusive evidence from many countries that exposure to cigarette smoke during pregnancy and after birth significantly increases the risk of SUDI. Following the success of the back to sleep campaigns, maternal smoking is now the most important modifiable risk factor for SUDI. This increased SUDI risk is likely due to the deleterious effects of nicotine exposure on autonomic control of heart rate and blood pressure and impairing of arousal responses from sleep.  

• Any reduction in maternal smoking during pregnancy decreases the risk of SUDI and mothers are encourage to try and reduce the number of cigarettes smoked as much as possible.
• As breast feeding is protective for SUDI the advice to breastfeed is an important SUDI risk-reduction message in mothers who smoke.
• It is recommended that the safest place for a baby to sleep is in a cot in the parents’ bedroom (room-sharing) for the first six to twelve months of life as this has been shown to lower the risk of SUDI and this is also the case for babies in families where one or both parents smoke.  
• Sharing a sleep surface with a baby (co-sleeping or bed-sharing) increases the risk of SUDI and a considerable proportion of SUDI occur on a shared sleeping surface. There is a very much greater risk of SUDI if the mother smokes or if both parents smoke, and share a sleep surface with their baby and this is particularly important for young babies under 3 months of age. Parents who smoke should be aware that co-sleeping or bed-sharing should be avoided.
• If fathers smoke, there is an independent additive increase in the risk of SUDI and smoke exposure should be minimised by smoking outside and never smoking around the baby in a confined space such as in the car.

Provide a safe sleeping environment night and day

The safest place for a baby to sleep is in a cot in the same room as parents/caregivers. The sleeping surface should be clean, flat and firm. It is important that the mattress fits snugly in the cot so that the baby cannot become wedged between the mattress and the cot frame. There should be no soft or loose bedding, pillows, cot bumpers, lambs wools or soft toys in the cot which could cover the baby’s face. Sleep surfaces with inclines of >10 degrees are unsafe for infant sleep as babies are at higher risk of SUDI from suffocation or strangulation, if they sleep in inclined or propped positions. Between2001 and 2021, 151 infants in Australia died in inclined products such as rockers, bouncers, and on items that were propped.

• The Australian Government has developed mandatory standards for cots and portable cots (from March 2009) and all cots, new and second hand, sold in Australia must meet the Australian Standard for cots (AS/NZS 2172-2003). Safety requirements for cots regarding height and gaps around the mattress are currently mandatory, but the test method set out in the Australian Standard for ‘sleep surfaces – test for firmness’ is a voluntary standard (Australian/New Zealand standard AS/NZS 8811.1:2013 Sleep surfaces – test for firmness).
• In addition, the voluntary mattress firmness test is only in place for mattresses supplied with the cot, not mattresses sold separately. There is no mandatory Australian standard to check for when buying many other nursery products. New mandatory standards for infant sleep products and inclined non-sleep products were introduced on 18 July 2024. Businesses have 18 months to meet the new rules.‍
• Unlike cots, there is no Australian Standard for bassinets. Babies grow quickly and may grow out of a bassinet as early as a 2 months of age. As each bassinet comes with different recommendations as to when to move to a cot it will also depend on how big and how quickly your baby grows. Bassinets should not be used once a baby can roll over or pull themselves up the side of the bassinet, which is usually around 4-6 months of age.
• It is important for parents when they are thinking of buying a product for their baby to be able to make the best informed decision based on evidence of product safety. This is crucial for preventing SUDI or other fatal sleeping accidents. It is often assumed that all nursery products sold in retail stores must be safe, however many products have never been formally tested so it can be difficult to tell what is safe for your baby.

Sleep baby in their own safe sleeping place in the same room as an adult care-giver for the first six to twelve months

Room-sharing, but not bed-sharing, with your baby reduces the risk of SUDI by up to 50%.

• Room-sharing facilitates a rapid response to your baby’s needs, supports breastfeeding, is more convenient for settling and comforting babies, and provides closer parent-baby contact and communication. Sensory stimulation (e.g. sounds and smells)of the baby through sharing the same room as a parent has been argued to increase arousals from sleep, reduce deep sleep, and support those protective airway mechanisms that are thought to reduce risk of SUDI.

Breastfeed baby

Breastfeeding is the optimal source of nutrition for your baby, with many benefits for both mother and baby. Breastfeeding has been shown to reduce the risk of SUDI by up to 50%.

• All mothers, including those who smoke, are encouraged to breastfeed their babies.
• The specific mechanisms by which breastfeeding is protective is not fully understood, but are believed to be multifactorial and related to breastmilk components, maternal behaviour and the mechanism of breastfeeding.
• Physiological studies on sleeping infants have demonstrated that breast fed infants are more easily aroused from sleep compared to formula fed infants. In addition, breastfeeding is associated with a decreased incidence of diarrhoea, both upper and lower respiratory tract infections and other infectious diseases.

Other recommendations for safe sleep.

Bed sharing or sharing a sleep surface with your baby

Sharing a sleep surface with your baby can increase the risk of SUDI even if the baby is breastfed and the parents do not smoke.

• Bed sharing is an increased risk particularly if the baby is under 3 months of age or has been born prematurely or small for their age.
• Bed sharing is a very much greater risk if either parent smokes, drinks alcohol or takes illicit drugs.
• Recent evidence shows that more than half of all SUDI cases occur whilst the baby is bed sharing.
• There is no increased risk of SUDI whilst sharing a sleep surface with a baby during feeding, cuddling and playing providing that the baby is returned to a cot or their own safe sleeping surface before the parent goes back to sleep.
• Falling asleep on a sofa or couch is a particular risk. Often parents/carers will fall asleep unintentionally on a sofa or couch and there is a very high risk of a sleeping accident in this situation as the baby may become wedged into cushions or the back of the sofa, or even fall onto the floor injuring themselves.
• Sleeping your baby on their tummy on your chest, is an excellent strategy for settling, and helping them to self-regulate, as long as the baby and their airway are being observed. A parent falling asleep with a baby on the tummy on the parent’s chest and unobserved can be a risk as prone positioning reduces the arousal mechanisms that protect baby’s airway. In addition, the baby’s nose may become obstructed by clothing, or the parent’s body or breast, or the baby may become positioned with his/her chin to chest, which will also obstruct the baby’s airway.

Infant swaddling or wrapping

Swaddling or wrapping your baby is a useful strategy to calm them and promote back sleeping. Currently there is no evidence to recommend swaddling or wrapping as a strategy to reduce the risk of SUDI.

• Use only lightweight wraps such as cotton or muslin (bunny rugs and blankets are not safe as they may cause overheating). The wrap should be firm, to prevent loose wrapping becoming loose bedding, which could cover your baby’s face. However, the wrap should not be too tight and must allow for hip and chest wall movement.
• If babies are swaddled or wrapped, they must always be placed on their back. There is a greatly increased risk of death if a swaddled baby is placed, or rolls onto their tummy.
• Current evidence strongly suggests that as soon as baby shows signs of beginning to roll, wrapping should be ceased for sleep periods.
• An alternative to wrapping is to use a safe infant sleeping bag; one with a fitted neck and armholes that is the right size for the baby’s weight. Clothing can be layered underneath the sleeping bag according to climate conditions. However, as yet there is no evidence that sleeping bags are protective against SUDI.
• A wide range of products designed as infant swaddles, wraps and wearable blankets, have proliferated on the market and are available to parents. It is important to be aware that there is very limited evidence to support the use of these products as devices to promote infant settling, back sleeping and no evidence to support these products as a strategy to reduce the risk of infant death.
• Devices which use Velcro to securely wrap the baby are not recommended as there is a risk that if the infant turns onto their tummy or their face becomes covered in bedding they will not be able to move to escape potentially suffocating positions. Deaths and injuries of infants using these products have been reported in the USA.

Dummy (pacifier) use is protective

Studies have consistently reported a reduced risk of SUDI associated with dummy use, with a more than halving of the risk of SUDI.

• A dummy can be offered after breast feeding is established and should be used consistently for every sleep.
• Dummies can be offered to bottle-fed infants from birth.
• The mechanism by which dummies might reduce the risk of SUDI, or by their absence increase the risk, is not fully understood. Several mechanisms have been suggested including avoidance of the prone sleeping position, protection of the airway as sucking on a dummy keeps the tongue forward maintaining upper airway patency and keeping the nose clear of bedding.

immunisation is protective

No study has demonstrated an increased risk of SUDI with immunisation in fact studies have confirmed that SUDI rate is nearly halved in immunised babies compared with those not immunised. Similarly, no study has shown an increase in autism with immunisation. Immunisation is a simple, safe and effective way of protecting against a number of infective diseases.

Home monitoring does not prevent SUDI

Baby breathing monitors are not indicated for normal healthy babies and toddlers. There is no scientific evidence that using any type of monitor will prevent a sudden unexpected infant death, despite claims from some manufacturers these devices.

• Monitor use is disruptive for most families and unnecessary for most babies.
• In a very small number of cases, health professionals may recommend the use of home monitors, where their use can be helpful for babies and families.

The safe use of baby carriers and slings

Baby carriers and slings can be a risk for SUDI if not use appropriately.

• Adult worn slings are baby carriers are usually made of soft fabric and allow an adult to carry an infant hands-free. The sling straps around the adult’s neck, allowing the infant to lie in front of the adult, curved in a C-shape position.
• Strap on carriers allow the infant to be in a vertical position with the infant’s head facing that of the carrier.
• Slings and strap on carriers are becoming increasingly popular in Western countries with about a million sold annually in the USA alone.
• Babies can suffocate lying with a curved back with the chin resting on the chest or the face pressed against the fabric of the sling or the wearer’s body.
• Parents should follow the T.I.C.K.S. guide to safe carrying of their infant in a sling.

Further information

• Red Nose website

Other useful links:

• Tips to Help Baby Sleep Better
• Pregnancy and Sleep
• Sleep Tips for New Mothers
• Anxiety and Sleep
• Depression and Sleep
• How much sleep do you really need?